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Wade CE, Baer LA, Wu X, Silliman DT, Walters TJ, Wolf SE. Severe burn and disuse in the rat independently adversely impact body composition and adipokines. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R225. [PMID: 24099533 PMCID: PMC4057079 DOI: 10.1186/cc13048] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 08/28/2013] [Indexed: 12/26/2022]
Abstract
Introduction Severe trauma is accompanied by a period of hypermetabolism and disuse. In this study, a rat model was used to determine the effects of burn and disuse independently and in combination on body composition, food intake and adipokines. Methods Male rats were assigned to four groups 1) sham ambulatory (SA), 2) sham hindlimb unloaded (SH), 3) 40% total body surface area full thickness scald burn ambulatory (BA) and 4) burn and hindlimb unloaded (BH). Animals designated to the SH and BH groups were placed in a tail traction system and their hindlimbs unloaded. Animals were followed for 14 days. Plasma, urine, fecal and tissue samples were analyzed. Results SA had a progressive increase in body mass (BM), SH and BA no change and BH a reduction. Compared to SA, BM was reduced by 10% in both SH and BA and by 17% when combined in BH. Compared to SA, all groups had reductions in lean and fat body mass with BH being greater. The decrease in lean mass was associated with the rate of urinary corticosterone excretion. The loss in fat mass was associated with decreases in plasma leptin and adiponectin and an increase in ghrelin. Following the acute response to injury, BH had a greater food intake per 100 g BM. Food intake was associated with the levels of leptin, adiponectin and ghrelin. Conclusions The effects of the combination of burn and disuse in this animal model were additive, therefore in assessing metabolic changes with severe trauma both injury and disuse should be considered. Furthermore, the observed changes in adipokines, corticosterone and ghrelin provide insights for interventions to attenuate the hypermetabolic state following injury, possibly reducing catabolism and muscle loss and subsequent adverse effects on recovery and function.
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Walking acute respiratory distress syndrome: a target for treatment and prevention?*. Crit Care Med 2013; 41:2046-7. [PMID: 23863243 DOI: 10.1097/ccm.0b013e3182963c15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hart N, Barreiro E. Feast or Famine in the Intensive Care Unit: Does It Really Matter? Am J Respir Crit Care Med 2013; 188:523-5. [DOI: 10.1164/rccm.201306-1162ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Bice T, Cox CE, Carson SS. Cost and health care utilization in ARDS--different from other critical illness? Semin Respir Crit Care Med 2013; 34:529-36. [PMID: 23934722 DOI: 10.1055/s-0033-1351125] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Costs of care in the intensive care unit are a frequent target for concern in the current health care system. Utilization of critical care services in the United States is increasing and will continue to do so. Acute respiratory distress syndrome (ARDS) is a common and important complication of critical illness. Patients with ARDS frequently have long hospitalizations and consume a significant amount of health care resources. Many patients are discharged with functional limitations and high susceptibility to new complications that require significant additional health care resources. There is increasing literature on the cost-effectiveness of the treatment of ARDS, and despite its high costs, treatment remains a cost-effective intervention by current societal standards. However, when ARDS leads to prolonged mechanical ventilation, treatment becomes less cost-effective. Current research seeks to find interventions that lead to reductions in duration of mechanical ventilation and intensive care unit (ICU) length of stay. Limited reductions in ICU length of stay have benefits for the patient, but they do not lead to significant reductions in overall hospital costs. Early discharge to post-acute care facilities can reduce hospital costs but are unlikely to decrease costs for an entire episode of illness. Improved effectiveness of communication between clinicians and patients or their surrogates could help avoid costly interventions with poor expected outcomes.
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Affiliation(s)
- Thomas Bice
- Division of Pulmonary and Critical Care Medicine, University of North Carolina Medical Center, Chapel Hill, NC 27599, USA
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Abstract
A large fraction of intensive care unit (ICU) patients with respiratory failure who survive their critical illness leave the hospital with substantial neuromuscular weakness. In light of this reality, a shift in the approach to critical care management has begun. This viewpoint has broadened the perspective of ICU care providers beyond the narrow goal of leaving the ICU alive to a broader notion focused on minimizing the complications that accompany the inherent noxious nature of ICU care. Mobilization of mechanically ventilated patients is feasible, safe, and carries the potential for tremendous benefit for our patients.
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Affiliation(s)
- John P Kress
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL 60637, USA.
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Banduseela VC, Chen YW, Kultima HG, Norman HS, Aare S, Radell P, Eriksson LI, Hoffman EP, Larsson L. Impaired autophagy, chaperone expression, and protein synthesis in response to critical illness interventions in porcine skeletal muscle. Physiol Genomics 2013; 45:477-86. [PMID: 23572537 DOI: 10.1152/physiolgenomics.00141.2012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Critical illness myopathy (CIM) is characterized by a preferential loss of the motor protein myosin, muscle wasting, and impaired muscle function in critically ill intensive care unit (ICU) patients. CIM is associated with severe morbidity and mortality and has a significant negative socioeconomic effect. Neuromuscular blocking agents, corticosteroids, sepsis, mechanical ventilation, and immobilization have been implicated as important risk factors, but the causal relationship between CIM and the risk factors has not been established. A porcine ICU model has been used to determine the immediate molecular and cellular cascades that may contribute to the pathogenesis prior to myosin loss and extensive muscle wasting. Expression profiles have been compared between pigs exposed to the ICU interventions, i.e., mechanically ventilated, sedated, and immobilized for 5 days, with pigs exposed to critical illness interventions, i.e., neuromuscular blocking agents, corticosteroids, and induced sepsis in addition to the ICU interventions for 5 days. Impaired autophagy as well as impaired chaperone expression and protein synthesis were observed in the skeletal muscle in response to critical illness interventions. A novel finding in this study is impaired core autophagy machinery in response to critical illness interventions, which when in concert with downregulated chaperone expression and protein synthesis may collectively affect the proteostasis in skeletal muscle and may exacerbate the disease progression in CIM.
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Affiliation(s)
- Varuna C Banduseela
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden.
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Briegel I, Dolch M, Irlbeck M, Hauer D, Kaufmann I, Schelling G. [Quality of results of therapy of acute respiratory failure : changes over a period of two decades]. Anaesthesist 2013; 62:261-70. [PMID: 23558717 DOI: 10.1007/s00101-013-2156-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 02/20/2013] [Accepted: 02/21/2013] [Indexed: 12/15/2022]
Abstract
Progress in intensive care (ICU) treatment of acute respiratory distress syndrome (ARDS) over the last 20 years includes the introduction of extracorporeal membrane oxygenation (ECMO) for CO2 removal and the widespread use of evidence-based lung-protective ventilatory strategies. Little is known, however, about whether these changes have resulted in improvements in short-term and long-term outcome of acute respiratory distress syndrome (ARDS) within the two decades after introduction. In a retrospective study 167 long-term survivors of severe ARDS who were transferred to the clinic for anesthesiology of the University of Munich, Campus Großhadern by means of specialized intensive care unit (ICU) transport teams and treated over a period of 20 years (1985-2005) were evaluated to investigate whether significant improvements in outcome as a consequence of the above mentioned progress in ARDS therapy have occurred. The ARDS patient cohort studied was characterized with regard to demographic variables, initial acute physiology and chronic health evaluation (APACHE) II score, duration of ICU treatment, the duration of mechanical ventilation and mortality. Data on long-term outcome were collected in a subcohort (n = 125) of patients who responded to mailed questionnaires and included health-related quality of life (HRQL, SF-36 questionnaire), symptoms of post-traumatic stress disorder (PTSD), traumatic memories from ICU treatment (PTSS-10 instrument) and current state of employment. During the observation period no significant changes regarding patient age (39 ± 16 years, mean ± SD), disease severity on admission to the ICU (APACHE II scores 22 ± 5), duration of ICU treatment (47 ± 39 days) or duration of mechanical ventilation (39 ± 38 days) were found. Overall ICU mortality during the two decades was 37.3 % (range 25.0 %-38.1 %) between 1995 and 2001 and a non-significant increase in values between 36.8 % and 58.3 % during the time interval from 2002 und 2005. The paO2/FIO2-ratio on ICU admittance improved significantly between 1990 and 2000 (69 ± 5 between 1990 and 1994 versus 101 ± 12 between 1995 and 2000, p < 0.01) and remained nearly unchanged thereafter. Long-term outcome was evaluated on average 5.0 ± 3.1 years after discharge from the ICU. During the time period between 1985 and 1994 survivors of ARDS showed significant impairments in all 8 categories of the SF-36 HRQL instrument when compared to an age and sex-matched normal population with maximal differences regarding physical function (z = -1.01), general health perception (z = -1.17) and mental health (z = -1.3). Patients who were treated from 1995 to 2005 were still impaired in 7 out of 8 categories of HRQL but reported significantly better mental health (49.6 ± 16.5 vs. 68.6 ± 17.8, p < 0,01) and better physical function than individuals from the previous decade (49.6 ± 16.5 vs. 73.4 ± 27.5, p = 0,03). The difference of mental health was no longer significant when compared to a healthy age and sex matched control group (p = 0.14) but the difference in physical function still was (z = -0.48, p < 0.01). The incidence of severe post-traumatic stress defined as a PTSS-10 score ≥ 35 was 20.4 % and remained unchanged throughout the 2 decades of observation. The PTSS-10 scores correlated with the number of traumatic memories present (r = 0.43, p < 0.01, n = 125). More than 50 % of long-term survivors were able to return to full time work with no significant changes during the 2 decades of observation. The introduction of new modalities of ARDS treatment were associated with higher paO2/FIO2-ratios on ICU admittance but had no effect on short-term outcomes including duration of ICU therapy, mechanical ventilation or mortality. The ARDS patients are still at risk for post-traumatic stress and persistent impairments in HRQL. Apart from some improvements in HRQL, the outcome of ARDS therapy remained largely unchanged during two decades.
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Affiliation(s)
- I Briegel
- Klinik für Anaesthesiologie, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland.
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Wilcox ME, Patsios D, Murphy G, Kudlow P, Paul N, Tansey CM, Chu L, Matte A, Tomlinson G, Herridge MS. Radiologic Outcomes at 5 Years After Severe ARDS. Chest 2013. [DOI: 10.1378/chest.12-0685] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Ferguson M, Bianchi MT, Sutter R, Rosenthal ES, Cash SS, Kaplan PW, Westover MB. Calculating the risk benefit equation for aggressive treatment of non-convulsive status epilepticus. Neurocrit Care 2013; 18:216-27. [PMID: 23065689 PMCID: PMC3767472 DOI: 10.1007/s12028-012-9785-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To address the question: does non-convulsive status epilepticus warrant the same aggressive treatment as convulsive status epilepticus? METHODS We used a decision model to evaluate the risks and benefits of treating non-convulsive status epilepticus with intravenous anesthetics and ICU-level aggressive care. We investigated how the decision to use aggressive versus non-aggressive management for non-convulsive status epilepticus impacts expected patient outcome for four etiologies: absence epilepsy, discontinued antiepileptic drugs, intraparenchymal hemorrhage, and hypoxic ischemic encephalopathy. Each etiology was defined by distinct values for five key parameters: baseline mortality rate of the inciting etiology; efficacy of non-aggressive treatment in gaining control of seizures; the relative contribution of seizures to overall mortality; the degree of excess disability expected in the case of delayed seizure control; and the mortality risk of aggressive treatment. RESULTS Non-aggressive treatment was favored for etiologies with low morbidity and mortality such as absence epilepsy and discontinued antiepileptic drugs. The risk of aggressive treatment was only warranted in etiologies where there was significant risk of seizure-induced neurologic damage. In the case of post-anoxic status epilepticus, expected outcomes were poor regardless of the treatment chosen. The favored strategy in each case was determined by strong interactions of all five model parameters. CONCLUSIONS Determination of the optimal management approach to non-convulsive status epilepticus is complex and is ultimately determined by the inciting etiology.
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Affiliation(s)
- Matthew Ferguson
- Department of Neurology, Massachusetts general Hospital, Boston, MA, USA
| | - Matt T. Bianchi
- Department of Neurology, Massachusetts general Hospital, Boston, MA, USA
| | - Raoul Sutter
- Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurology, Johns Hopkins Bayview Medical, Center, Baltimore, MD, USA
| | - Eric S. Rosenthal
- Department of Neurology, Massachusetts general Hospital, Boston, MA, USA
| | - Sydney S. Cash
- Department of Neurology, Massachusetts general Hospital, Boston, MA, USA
| | - Peter W. Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical, Center, Baltimore, MD, USA
| | - M. Brandon Westover
- Department of Neurology, Massachusetts general Hospital, Boston, MA, USA; Wang 7 Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Morandi A, Pandharipande PP, Jackson JC, Bellelli G, Trabucchi M, Ely EW. Understanding terminology of delirium and long-term cognitive impairment in critically ill patients. Best Pract Res Clin Anaesthesiol 2013; 26:267-76. [PMID: 23040280 DOI: 10.1016/j.bpa.2012.08.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 08/01/2012] [Indexed: 11/29/2022]
Abstract
Delirium, an acute brain dysfunction, frequently affects intensive care unit (ICU) patients during the course of a critical illness. Besides the acute morbidities, ICU survivors often experience long-term sequelae in the form of cognitive impairment (LTCI-CI). Though delirium and LTCI-CI are associated with adverse outcomes, little is known on the terminology used to define these acute and chronic co-morbidities. The use of a correct terminology is a key factor to spread the knowledge on clinical conditions. Therefore, we first review the epidemiology, definition of delirium and its related terminology. Second, we report on the epidemiology of LTCI-CI and compare its definition to other forms of cognitive impairments. In particular, we define mild cognitive impairment, dementia and finally postoperative cognitive dysfunction. Future research is needed to interpret the trajectories of LTCI-CI, to differentiate it from neurodegenerative diseases and to provide a formal disease classification.
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Affiliation(s)
- A Morandi
- Department of Rehabilitation and Aged Care Unit Hospital Ancelle, Cremona, Italy.
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213
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Sud S, Sud M, Friedrich JO, Wunsch H, Meade MO, Ferguson ND, Adhikari NKJ. High-frequency ventilation versus conventional ventilation for treatment of acute lung injury and acute respiratory distress syndrome. Cochrane Database Syst Rev 2013:CD004085. [PMID: 23450549 DOI: 10.1002/14651858.cd004085.pub3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND High frequency oscillation is an alternative to conventional mechanical ventilation that is sometimes used to treat patients with acute respiratory distress syndrome, but effects on oxygenation, mortality and adverse clinical outcomes are uncertain. This review was originally published in 2004 and was updated in 2011. OBJECTIVES To determine clinical and physiological effects of high frequency oscillation (HFO) in patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) compared to conventional ventilation. SEARCH METHODS We electronically searched CENTRAL (Ovid), MEDLINE (Ovid), EMBASE (Ovid), and ISI (from inception to March 2011). The original search was performed in 2002. We manually searched reference lists from included studies and review articles; searched conference proceedings of the American Thoracic Society (1994 to 2010), Society of Critical Care Medicine (1994 to 2010), European Society of Intensive Care Medicine (1994 to 2010), and American College of Chest Physicians (1994 to 2010); contacted clinical experts in the field; and searched for unpublished and ongoing trials in clinicaltrials.gov and controlled-trials.com. SELECTION CRITERIA Randomized controlled clinical trials comparing treatment using HFO with conventional mechanical ventilation for children and adults diagnosed with ALI or ARDS. DATA COLLECTION AND ANALYSIS Three authors independently extracted data on clinical, physiological, and safety outcomes according to a predefined protocol. We contacted investigators of all included studies to clarify methods and obtain additional data. We used random-effects models in the analyses. MAIN RESULTS Eight RCTs (n = 419) were included; almost all patients had ARDS. The risk of bias was low in six studies and unclear in two studies. The quality of evidence for hospital and six-month mortality was moderate and low, respectively. The ratio of partial pressure of oxygen to inspired fraction of oxygen at 24, 48, and 72 hours was 16% to 24% higher in patients receiving HFO. There were no significant differences in oxygenation index because mean airway pressure rose by 22% to 33% in patients receiving HFO (P < 0.01). In patients randomized to HFO, mortality was significantly reduced (RR 0.77, 95% CI 0.61 to 0.98; P = 0.03; 6 trials, 365 patients, 160 deaths) and treatment failure (refractory hypoxaemia, hypercapnoea, hypotension, or barotrauma) was less likely (RR 0.67, 95% CI 0.46 to 0.99; P = 0.04; 5 trials, 337 patients, 73 events). Other risks, including adverse events, were similar. We found substantial between-trial statistical heterogeneity for physiological (I(2) = 21% to 95%) but not clinical (I(2) = 0%) outcomes. Pooled results were based on few events for most clinical outcomes. AUTHORS' CONCLUSIONS The findings of this systematic review suggest that HFO was a promising treatment for ALI and ARDS prior to the uptake of current lung protective ventilation strategies. These findings may not be applicable with current conventional care, pending the results of large multi-centre trials currently underway.
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Affiliation(s)
- Sachin Sud
- Division of Critical Care, Department of Medicine, Trillium Health Center, University of Toronto, Mississauga, Canada.
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214
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Cross LJM, O’Kane CM, McDowell C, Elborn JJ, Matthay MA, McAuley DF. Keratinocyte growth factor in acute lung injury to reduce pulmonary dysfunction--a randomised placebo-controlled trial (KARE): study protocol. Trials 2013; 14:51. [PMID: 23419093 PMCID: PMC3620926 DOI: 10.1186/1745-6215-14-51] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 01/18/2013] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Acute lung injury is a common, devastating clinical syndrome associated with substantial mortality and morbidity with currently no proven therapeutic interventional strategy to improve patient outcomes. The objectives of this study are to test the potential therapeutic effects of keratinocyte growth factor for patients with acute lung injury on oxygenation and biological indicators of acute inflammation, lung epithelial and endothelial function, protease:antiprotease balance, and lung extracellular matrix degradation and turnover. METHODS/DESIGN This will be a prospective, randomised, double-blind, allocation-concealed, placebo-controlled, phase 2, multicentre trial. Randomisation will be stratified by presence of severe sepsis requiring vasopressors. Patients in an ICU fulfilling the American-European Consensus Conference Definition of acute lung injury will be randomised in a 1:1 ratio to receive an intravenous bolus of either keratinocyte growth factor (palifermin, 60 μg/kg) or placebo (0.9% sodium chloride solution) daily for a maximum of 6 days. The primary endpoint of this clinical study is to evaluate the efficacy of palifermin to improve the oxygenation index at day 7 or the last available oxygenation index prior to patient discontinuation from the study.A formal statistical analysis plan has been constructed. Analyses will be carried out on an intention-to-treat basis. A single analysis is planned at the end of the trial. P = 0.05 will be considered statistically significant and all tests will be two-sided. For continuously distributed outcomes, differences between groups will be tested using independent-sample t tests, analysis of variance and analysis of covariance with transformation of variables to normality or nonparametric equivalents. The trial will be reported in line with the Consolidated Standards of Reporting Trials (Consort 2010 guidelines). TRIAL REGISTRATION ISRCTN95690673.
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Affiliation(s)
- Laurence JM Cross
- Centre for Infection and Immunity, The Queen’s University of Belfast, Health Sciences Building, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Cecilia M O’Kane
- Centre for Infection and Immunity, The Queen’s University of Belfast, Health Sciences Building, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Cliona McDowell
- Clinical Research Support Centre, Royal Victoria Hospital, Belfast Health and Social Care Trust, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Jospeh J Elborn
- Centre for Infection and Immunity, The Queen’s University of Belfast, Health Sciences Building, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Michael A Matthay
- Cardiovascular Research Institute, University of California, San Francisco, 505 Parnassus Avenue, M-917, San Francisco, CA, 94143-0624, USA
- Departments of Medicine and Anesthesia, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Daniel F McAuley
- Centre for Infection and Immunity, The Queen’s University of Belfast, Health Sciences Building, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
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Kradin RL. Guiding the pulmonologist's hand: What they need to know about lung pathology and what is lost in translation. Arch Pathol Lab Med 2013. [PMID: 23194046 DOI: 10.5858/arpa.2012-0273-sa] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Increasing subspecialization in the practice of medicine has led to certain discrepancies in how pathologists and pulmonologists imagine lung disease. This article, written by a pathologist who also practices pulmonology at a large, academic hospital, highlights his perspective on the important role of the pathologist in guiding the hand of the pulmonary clinician.
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Affiliation(s)
- Richard L Kradin
- Pulmonary and Critical Care Unit, Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA.
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216
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Nardelli P, Khan J, Powers R, Cope TC, Rich MM. Reduced motoneuron excitability in a rat model of sepsis. J Neurophysiol 2013; 109:1775-81. [PMID: 23303860 DOI: 10.1152/jn.00936.2012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Many critically ill patients in intensive care units suffer from an infection-induced whole body inflammatory state known as sepsis, which causes severe weakness in patients who survive. The mechanisms by which sepsis triggers intensive care unit-acquired weakness (ICUAW) remain unclear. Currently, research into ICUAW is focused on dysfunction of the peripheral nervous system. During electromyographic studies of patients with ICUAW, we noticed that recruitment was limited to few motor units, which fired at low rates. The reduction in motor unit rate modulation suggested that functional impairment within the central nervous system contributes to ICUAW. To understand better the mechanism underlying reduced firing motor unit firing rates, we moved to the rat cecal ligation and puncture model of sepsis. In isoflurane-anesthetized rats, we studied the response of spinal motoneurons to injected current to determine their capacity for initiating and firing action potentials repetitively. Properties of single action potentials and passive membrane properties of motoneurons from septic rats were normal, suggesting excitability was normal. However, motoneurons exhibited striking dysfunction during repetitive firing. The sustained firing that underlies normal motor unit activity and smooth force generation was slower, more erratic, and often intermittent in septic rats. Our data are the first to suggest that reduced excitability of neurons within the central nervous system may contribute to ICUAW.
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Affiliation(s)
- Paul Nardelli
- Department of Neuroscience, Cell Biology, and Physiology, Wright State University, Dayton, OH, USA
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217
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Neurologic Implications of Critical Illness and Organ Dysfunction. TEXTBOOK OF NEUROINTENSIVE CARE 2013. [PMCID: PMC7119948 DOI: 10.1007/978-1-4471-5226-2_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Critical illness has consequences for the nervous system. Patients experiencing critical illness are at risk for common global neurologic disturbances, such as delirium, long-term cognitive dysfunction, ICU-acquired weakness, sleep disturbances, recurrent seizures, and coma. In addition, complications related to specific organ dysfunction may be anticipated. Cardiovascular disease presents the possibility for CNS injury after cardiac arrest, sequelae of endocarditis, aberrancies of blood flow autoregulation, and malperfusion. Respiratory disease is known to cause short-term effects of hypoxia and long-term effects after ARDS. Sepsis encephalopathy and sickness behavior syndrome are early signs of infection in patients. In addition, commonly encountered organ dysfunction including uremia, hepatic failure, endocrine, and metabolic disturbances present with neurologic findings which may manifest in the critically ill patient as well.
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218
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Luyt CE, Combes A, Becquemin MH, Beigelman-Aubry C, Hatem S, Brun AL, Zraik N, Carrat F, Grenier PA, Richard JCM, Mercat A, Brochard L, Brun-Buisson C, Chastre J. Long-term outcomes of pandemic 2009 influenza A(H1N1)-associated severe ARDS. Chest 2013; 142:583-592. [PMID: 22948576 DOI: 10.1378/chest.11-2196] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND No data on long-term outcomes of survivors of 2009 influenza A(H1N1) (A[H1N1])-associated ARDS are available. The objective of this study was to compare the 1-year outcomes of survivors of A(H1N1)-associated ARDS, according to use or no use of extracorporeal lung assist (ECLA), using its need as an ARDS severity surrogate. METHODS Survivors of ARDS (12 with ECLA use vs 25 without, corresponding to 75% and 54% of the eligible patients for each group, respectively) selected from the Réseau Européen de Ventilation Artificielle (REVA) registry had previously been healthy, with only pregnancy and/or moderate obesity (BMI ≤ 35 kg/m²) as known risk factors for A(H1N1) infection. Lung function and morphology, health-related quality of life (HRQoL), and psychologic impairment were evaluated. RESULTS At 1 year post-ICU discharge for the ECLA and no-ECLA groups, respectively, 50% and 40% reported significant exertion dyspnea, 83% and 64% had returned to work, and 75% and 64% had decreased diffusion capacity across the blood-gas barrier, despite their near-normal and similar lung function test results. For both groups, exercise test results showed diminished but comparable exercise capacities, with similar alveolar-arterial oxygen gradients at peak exercise, and CT scans showed minor abnormal findings. HRQoL assessed by the 36-Item Short-Form Health Survey was poorer for both groups than for a sex- and age-matched general population group, but without between-group differences. ECLA and no-ECLA group patients, respectively, had symptoms of anxiety (50% and 56%) and depression (28% and 28%) and were at risk for posttraumatic stress disorder (41% and 44%). CONCLUSIONS One year post-ICU discharge, a majority of survivors of A(H1N1)-associated ARDS had minor lung disabilities with diminished diffusion capacities across the blood-gas barrier, and most had psychologic impairment and poorer HRQoL than a sex- and age-matched general population group. ECLA and no-ECLA group patients had comparable outcomes. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01271842; URL: www.clinicaltrials.gov
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Affiliation(s)
- Charles-Edouard Luyt
- Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris et Université Paris 6-Pierre-et-Marie-Curie, Paris France.
| | - Alain Combes
- Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris et Université Paris 6-Pierre-et-Marie-Curie, Paris France
| | - Marie-Hélène Becquemin
- Service d'Explorations Fonctionnelles, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris et Université Paris 6-Pierre-et-Marie-Curie, Paris France
| | - Catherine Beigelman-Aubry
- Service de Radiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris et Université Paris 6-Pierre-et-Marie-Curie, Paris France
| | - Stéphane Hatem
- Service d'explorations fonctionnelles cardio-vasculaires, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris et Université Paris 6-Pierre-et-Marie-Curie, Paris France
| | - Anne-Laure Brun
- Service de Radiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris et Université Paris 6-Pierre-et-Marie-Curie, Paris France
| | - Nizar Zraik
- Service d'Explorations Fonctionnelles, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris et Université Paris 6-Pierre-et-Marie-Curie, Paris France
| | - Fabrice Carrat
- Service de Santé Publique, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Unité Mixte de Recherche-S 707, Institut National de la Santé et de la Recherche Médicale (INSERM), Université Paris 6-Pierre-et-Marie-Curie, Paris, France
| | - Philippe A Grenier
- Service de Radiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris et Université Paris 6-Pierre-et-Marie-Curie, Paris France
| | | | - Alain Mercat
- Service de Réanimation Médicale, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Laurent Brochard
- Intensive Care Unit, Hôpitaux Universitaires de Genève, Genève, Switzerland
| | - Christian Brun-Buisson
- Service de Réanimation Médicale, Hôpital Henri-Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris 12, Créteil, France
| | - Jean Chastre
- Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris et Université Paris 6-Pierre-et-Marie-Curie, Paris France
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FLAATTEN H. ARDS--insights from Iceland and definitions from Berlin. Acta Anaesthesiol Scand 2013; 57:1-2. [PMID: 23216359 DOI: 10.1111/aas.12021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- H. FLAATTEN
- Department of Anaesthesia and Intensive Care; General ICU; Haukeland University Hospital; Bergen; Norway
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Financial Implications of Starting a Mobility Protocol in a Surgical Intensive Care Unit. Crit Care Nurs Q 2013; 36:120-6. [DOI: 10.1097/cnq.0b013e3182753725] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Renaud G, Llano-Diez M, Ravara B, Gorza L, Feng HZ, Jin JP, Cacciani N, Gustafson AM, Ochala J, Corpeno R, Li M, Hedström Y, Ford GC, Nair KS, Larsson L. Sparing of muscle mass and function by passive loading in an experimental intensive care unit model. J Physiol 2012; 591:1385-402. [PMID: 23266938 DOI: 10.1113/jphysiol.2012.248724] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The response to mechanical stimuli, i.e., tensegrity, plays an important role in regulating cell physiological and pathophysiological function, and the mechanical silencing observed in intensive care unit (ICU) patients leads to a severe and specific muscle wasting condition. This study aims to unravel the underlying mechanisms and the effects of passive mechanical loading on skeletal muscle mass and function at the gene, protein and cellular levels. A unique experimental rat ICU model has been used allowing long-term (weeks) time-resolved analyses of the effects of standardized unilateral passive mechanical loading on skeletal muscle size and function and underlying mechanisms. Results show that passive mechanical loading alleviated the muscle wasting and the loss of force-generation associated with the ICU intervention, resulting in a doubling of the functional capacity of the loaded versus the unloaded muscles after a 2-week ICU intervention. We demonstrate that the improved maintenance of muscle mass and function is probably a consequence of a reduced oxidative stress revealed by lower levels of carbonylated proteins, and a reduced loss of the molecular motor protein myosin. A complex temporal gene expression pattern, delineated by microarray analysis, was observed with loading-induced changes in transcript levels of sarcomeric proteins, muscle developmental processes, stress response, extracellular matrix/cell adhesion proteins and metabolism. Thus, the results from this study show that passive mechanical loading alleviates the severe negative consequences on muscle size and function associated with the mechanical silencing in ICU patients, strongly supporting early and intense physical therapy in immobilized ICU patients.
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Affiliation(s)
- Guillaume Renaud
- Department of Neuroscience, Clinical Neurophysiology, University Hospital, Entrance 85, 3rd floor, SE-751 85 Uppsala, Sweden
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Neuromuscular electrical stimulation for intensive care unit-acquired weakness: protocol and methodological implications for a randomized, sham-controlled, phase II trial. Phys Ther 2012; 92:1564-79. [PMID: 22421734 PMCID: PMC3513483 DOI: 10.2522/ptj.20110437] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND As the population ages and critical care advances, a growing number of survivors of critical illness will be at risk for intensive care unit (ICU)-acquired weakness. Bed rest, which is common in the ICU, causes adverse effects, including muscle weakness. Consequently, patients need ICU-based interventions focused on the muscular system. Although emerging evidence supports the benefits of early rehabilitation during mechanical ventilation, additional therapies may be beneficial. Neuromuscular electrical stimulation (NMES), which can provide some muscular activity even very early during critical illness, is a promising modality for patients in the ICU. OBJECTIVE The objectives of this article are to discuss the implications of bed rest for patients with critical illness, summarize recent studies of early rehabilitation and NMES in the ICU, and describe a protocol for a randomized, phase II pilot study of NMES in patients receiving mechanical ventilation. DESIGN The study was a randomized, sham-controlled, concealed, phase II pilot study with caregivers and outcome assessors blinded to the treatment allocation. SETTING The study setting will be a medical ICU. PARTICIPANTS The study participants will be patients who are receiving mechanical ventilation for 1 day or more, who are expected to stay in the ICU for an additional 2 days or more, and who meet no exclusion criteria. INTERVENTION The intervention will be NMES (versus a sham [control] intervention) applied to the quadriceps, tibialis anterior, and gastrocnemius muscles for 60 minutes per day. MEASUREMENTS Lower-extremity muscle strength at hospital discharge will be the primary outcome measure. LIMITATIONS Muscle strength is a surrogate measure, not a patient-centered outcome. The assessments will not include laboratory, genetic, or histological measures aimed at a mechanistic understanding of NMES. The optimal duration or dose of NMES is unclear. CONCLUSIONS If NMES is beneficial, the results of the study will help advance research aimed at reducing the burden of muscular weakness and physical disability in survivors of critical illness.
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Abstract
Patients admitted to the intensive care unit (ICU) can develop a condition referred to as "ICU-acquired weakness." This condition is characterized by profound weakness that is greater than might be expected to result from prolonged bed rest. Intensive care unit-acquired weakness often is accompanied by dysfunction of multiple organ systems. Individuals with ICU-acquired weakness typically have significant activity limitations, often requiring physical assistance for even the most basic activities associated with bed mobility. Many of these individuals have activity limitations months to years after hospitalization. The purpose of this article is to review evidence that guides physical rehabilitation of people with ICU-acquired weakness. Included are diagnostic criteria, medical management, and prognostic indicators, as well as criteria for beginning physical rehabilitation, with an emphasis on patient safety. Data are presented indicating that rehabilitation can be implemented with very few adverse effects. Evidence is provided for appropriate measurement approaches and for physical intervention strategies. Finally, some of the key issues are summarized that should be investigated to determine the best intervention guidelines for individuals with ICU-acquired weakness.
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Abstract
BACKGROUND Weakness and debilitation are common following critical illness. Studies that assess whether early physical activity initiated in the intensive care unit (ICU) continues after a patient is transferred to a ward are lacking. OBJECTIVE The purpose of this study was to assess whether physical activity and mobility initiated during ICU treatment were maintained after patients were discharged from a single ICU to a ward. DESIGN This was a cohort study. METHODS Consecutive patients who were diagnosed with respiratory failure and admitted to the respiratory ICU (RICU) at LDS Hospital underwent early physical activity and mobility as part of usual care. Medical data, the number of requests for a physical therapy consultation or nursing assistance with ambulation at ICU discharge, and mobility data were collected during the first 2 full days on the ward. RESULTS Of the 72 patients who participated in the study, 65 had either a physical therapy consultation or a request for nursing assistance with ambulation at ward transfer. Activity level decreased in 40 participants (55%) on the first full ward day. Of the 61 participants who ambulated 100 ft (30.48 m) or more on the last full RICU day, 14 did not ambulate, 22 ambulated less than 100 ft, and 25 ambulated 100 ft or more on the first ward day. LIMITATIONS Limitations include lack of data regarding why activity was not performed on the ward, lack of longitudinal follow-up to assess effects of activity, and lack of generalizability to patients not transferred to a ward or not treated in an ICU with an early mobility program. CONCLUSIONS Despite the majority of participants having a physical therapy consultation or a request for nursing assistance with ambulation at the time of transfer to the medical ward, physical activity levels decreased in over half of participants on the first full ward day. The data suggest a need for education of ward staff regarding ICU debilitation, enhanced communication among care providers, and focus on the importance of patient-centered outcomes during and following ICU treatment.
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Safety and feasibility of an exercise prescription approach to rehabilitation across the continuum of care for survivors of critical illness. Phys Ther 2012; 92:1524-35. [PMID: 22879441 DOI: 10.2522/ptj.20110406] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Survivors of critical illness can experience long-standing functional limitations that negatively affect their health-related quality of life. To date, no model of rehabilitation has demonstrated sustained improvements in physical function for survivors of critical illness beyond hospital discharge. OBJECTIVE The aims of this study were: (1) to describe a model of rehabilitation for survivors of critical illness, (2) to compare the model to local standard care, and (3) to report the safety and feasibility of the program. DESIGN This was a cohort study. METHODS As part of a larger randomized controlled trial, 74 participants were randomly assigned, 5 days following admission to the intensive care unit (ICU), to a protocolized rehabilitation program that commenced in the ICU and continued on the acute care ward and for a further 8 weeks following hospital discharge as an outpatient program. Exercise training was prescribed based on quantitative outcome measures to achieve a physiological training response. RESULTS During acute hospitalization, 60% of exercise sessions were able to be delivered. The most frequently occurring barriers to exercise were patient safety and patient refusal due to fatigue. Point prevalence data showed patients were mobilized more often and for longer periods compared with standard care. Outpatient classes were poorly attended, with only 41% of the patients completing more than 70% of outpatient classes. No adverse events occurred. LIMITATIONS Limitations included patient heterogeneity and delayed commencement of exercise in the ICU due to issues of consent and recruitment. CONCLUSIONS Exercise training that commences in the ICU and continues through to an outpatient program is safe and feasible for survivors of critical illness. Models of care that maximize patient participation across the continuum of care warrant further investigation.
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Llano-Diez M, Renaud G, Andersson M, Marrero HG, Cacciani N, Engquist H, Corpeño R, Artemenko K, Bergquist J, Larsson L. Mechanisms underlying ICU muscle wasting and effects of passive mechanical loading. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R209. [PMID: 23098317 PMCID: PMC3682313 DOI: 10.1186/cc11841] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 10/22/2012] [Indexed: 02/05/2023]
Abstract
Introduction Critically ill ICU patients commonly develop severe muscle wasting and
impaired muscle function, leading to delayed recovery, with subsequent
increased morbidity and financial costs, and decreased quality of life for
survivors. Critical illness myopathy (CIM) is a frequently observed
neuromuscular disorder in ICU patients. Sepsis, systemic corticosteroid
hormone treatment and post-synaptic neuromuscular blockade have been
forwarded as the dominating triggering factors. Recent experimental results
from our group using a unique experimental rat ICU model show that the
mechanical silencing associated with CIM is the primary triggering factor.
This study aims to unravel the mechanisms underlying CIM, and to evaluate
the effects of a specific intervention aiming at reducing mechanical
silencing in sedated and mechanically ventilated ICU patients. Methods Muscle gene/protein expression, post-translational modifications (PTMs),
muscle membrane excitability, muscle mass measurements, and contractile
properties at the single muscle fiber level were explored in seven deeply
sedated and mechanically ventilated ICU patients (not exposed to systemic
corticosteroid hormone treatment, post-synaptic neuromuscular blockade or
sepsis) subjected to unilateral passive mechanical loading for 10 hours per
day (2.5 hours, four times) for 9 ± 1 days. Results These patients developed a phenotype considered pathognomonic of CIM; that
is, severe muscle wasting and a preferential myosin loss (P <
0.001). In addition, myosin PTMs specific to the ICU condition were observed
in parallel with an increased sarcolemmal expression and cytoplasmic
translocation of neuronal nitric oxide synthase. Passive mechanical loading
for 9 ± 1 days resulted in a 35% higher specific force (P <
0.001) compared with the unloaded leg, although it was not sufficient to
prevent the loss of muscle mass. Conclusion Mechanical silencing is suggested to be a primary mechanism underlying CIM;
that is, triggering the myosin loss, muscle wasting and myosin PTMs. The
higher neuronal nitric oxide synthase expression found in the ICU patients
and its cytoplasmic translocation are forwarded as a probable mechanism
underlying these modifications. The positive effect of passive loading on
muscle fiber function strongly supports the importance of early physical
therapy and mobilization in deeply sedated and mechanically ventilated ICU
patients.
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Acute respiratory distress syndrome after trauma: development and validation of a predictive model. Crit Care Med 2012; 40:2295-303. [PMID: 22809905 DOI: 10.1097/ccm.0b013e3182544f6a] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine early clinical predictors of acute respiratory distress syndrome after major traumatic injury and characterize the performance of this acute respiratory distress syndrome prediction model, and two previously published acute respiratory distress syndrome prediction models, in an independent cohort of severely injured patients. DESIGN Prospective cohort study. SETTING University-affiliated level I trauma center in Seattle, WA, and nine hospitals participating in the Inflammation and Host Response to Injury Consortium. PATIENTS Model derivation utilized data from 224 patients participating in a randomized controlled trial. All models were validated in an independent cohort of 1,762 trauma patients. MEASUREMENTS AND MAIN RESULTS Variables strongly associated with acute respiratory distress syndrome in bivariate analysis (p<.01) were entered into a multiple logistic regression equation to generate an acute respiratory distress syndrome predictive model. We evaluated the performance of all models using the area under the receiver operator characteristic curve. Acute respiratory distress syndrome occurred in 79 subjects (35%) belonging to the development cohort and in 423 subjects (24%) from the validation cohort. Multivariable predictors of acute respiratory distress syndrome after trauma included subject age, Acute Physiology and Chronic Health Evaluation II Score, injury severity score, and the presence of blunt traumatic injury, pulmonary contusion, massive transfusion, and flail chest injury (area under the receiver operator characteristic curve 0.79 [95% confidence interval 0.73, 0.85]). Validation of the prediction model resulted in an area under the receiver operator characteristic curve of 0.71 (95% confidence interval 0.68, 0.74). Our model's performance in the validation cohort was superior to that of two other published acute respiratory distress syndrome prediction models (0.65 [95% confidence interval 0.63, 0.68] and 0.66 [95% confidence interval 0.64, 0.69], p<.01 for all comparisons). CONCLUSIONS Using routinely available clinical data, our prediction model identifies patients at high risk for acute respiratory distress syndrome early after severe traumatic injury. This predictive model could facilitate enrollment of subjects into future clinical trials designed to prevent this serious complication.
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GRANJA C, AMARO A, DIAS C, COSTA-PEREIRA A. Outcome of ICU survivors: a comprehensive review. The role of patient-reported outcome studies. Acta Anaesthesiol Scand 2012; 56:1092-103. [PMID: 22471617 DOI: 10.1111/j.1399-6576.2012.02686.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2011] [Indexed: 01/01/2023]
Abstract
Problems survivors face after intensive care unit (ICU) discharge begin while they are still in the ward, where many of their specific problems may run unrecognized, but they assume a heavy weight when they arrive at their homes and face several kind of limitations, from being unable to climb stairs because of weight loss, asthenia, dyspnea or joint stiffness to anxiety, depression or post-traumatic stress disorder. Follow-up consultations have given us a better understanding of these specific problems, and the information gained has been used to improve intensive care itself and promote a quality service for patients and relatives. The aim of this article is to provide an overview on adult ICU outcome studies and discuss how they have influenced and improved the delivery of intensive care. We will explain how we went from real patients to outcome studies and what we have learned concerning the consequences of critical illness and critical care. Development of outcome studies, what we have learned through them and our own experience will be outlined focusing mainly in four topics: mortality, physical disability, neuropsychological disability and health-related quality of life. Interventions to improve outcome on these main topics will be presented, and we will explain how we went from outcome studies to clinical interventions, focusing on the most recent proposals of intervention to improve outcome.
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Affiliation(s)
| | - A. AMARO
- Department of Intensive Care; Hospital Pedro Hispano; Matosinhos; Portugal
| | - C. DIAS
- CINTESIS - Center for Research in Health Technologies and Health Systems; Faculty of Medicine of Porto; Porto; Portugal
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McAuley DF, Laffey JG, O’Kane CM, Cross M, Perkins GD, Murphy L, McNally C, Crealey G, Stevenson M. Hydroxymethylglutaryl-CoA reductase inhibition with simvastatin in acute lung injury to reduce pulmonary dysfunction (HARP-2) trial: study protocol for a randomized controlled trial. Trials 2012; 13:170. [PMID: 22985805 PMCID: PMC3543316 DOI: 10.1186/1745-6215-13-170] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 08/31/2012] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Acute lung injury (ALI) is a common devastating clinical syndrome characterized by life-threatening respiratory failure requiring mechanical ventilation and multiple organ failure. There are in vitro, animal studies and pre-clinical data suggesting that statins may be beneficial in ALI. The Hydroxymethylglutaryl-CoA reductase inhibition with simvastatin in Acute lung injury to Reduce Pulmonary dysfunction (HARP-2) trial is a multicenter, prospective, randomized, allocation concealed, double-blind, placebo-controlled clinical trial which aims to test the hypothesis that treatment with simvastatin will improve clinical outcomes in patients with ALI. METHODS/DESIGN Patients fulfilling the American-European Consensus Conference Definition of ALI will be randomized in a 1:1 ratio to receive enteral simvastatin 80 mg or placebo once daily for a maximum of 28 days. Allocation to randomized groups will be stratified with respect to hospital of recruitment and vasopressor requirement. Data will be recorded by participating ICUs until hospital discharge, and surviving patients will be followed up by post at 3, 6 and 12 months post randomization. The primary outcome is number of ventilator-free days to day 28. Secondary outcomes are: change in oxygenation index and sequential organ failure assessment score up to day 28, number of non pulmonary organ failure free days to day 28, critical care unit mortality; hospital mortality; 28 day post randomization mortality and 12 month post randomization mortality; health related quality of life at discharge, 3, 6 and 12 months post randomization; length of critical care unit and hospital stay; health service use up to 12 months post-randomization; and safety. A total of 540 patients will be recruited from approximately 35 ICUs in the UK and Ireland. An economic evaluation will be conducted alongside the trial. Plasma and urine samples will be taken up to day 28 to investigate potential mechanisms by which simvastatin might act to improve clinical outcomes. TRIAL REGISTRATION Current Controlled Trials ISRCTN88244364.
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Affiliation(s)
- Daniel F McAuley
- Centre for Infection and Immunity, Queen's University of Belfast, Belfast, BT9 7BL, UK
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, BT12 6BA, UK
- Clinical Research Support Centre, Royal Victoria Hospital, Belfast, BT12 6BA, UK
| | - John G Laffey
- Department of Anaesthesia, Clinical Sciences Institute, National University of Ireland, Galway, Ireland
| | - Cecilia M O’Kane
- Centre for Infection and Immunity, Queen's University of Belfast, Belfast, BT9 7BL, UK
| | - Mark Cross
- Centre for Infection and Immunity, Queen's University of Belfast, Belfast, BT9 7BL, UK
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, BT12 6BA, UK
| | - Gavin D Perkins
- Warwick Medical School Clinical Trials Unit, University of Warwick, Warwick, CV4 7AL, UK
| | - Lynn Murphy
- Clinical Research Support Centre, Royal Victoria Hospital, Belfast, BT12 6BA, UK
| | - Christine McNally
- Clinical Research Support Centre, Royal Victoria Hospital, Belfast, BT12 6BA, UK
| | - Grainne Crealey
- Clinical Research Support Centre, Royal Victoria Hospital, Belfast, BT12 6BA, UK
| | - Michael Stevenson
- Clinical Research Support Centre, Royal Victoria Hospital, Belfast, BT12 6BA, UK
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Fan E, Gifford JM, Chandolu S, Colantuoni E, Pronovost PJ, Needham DM. The functional comorbidity index had high inter-rater reliability in patients with acute lung injury. BMC Anesthesiol 2012; 12:21. [PMID: 22974239 PMCID: PMC3517372 DOI: 10.1186/1471-2253-12-21] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 08/31/2012] [Indexed: 01/26/2023] Open
Abstract
Background The Functional Comorbidity Index (FCI) was recently developed to predict physical function in acute lung injury patients using comorbidity data. Our objectives were to determine: (1) the inter-rater reliability of the FCI collected using in-patient discharge summaries (primary objective); and (2) the accuracy and predictive validity of the FCI collected using hospital discharge summaries and admission records versus complete chart review (secondary objectives). Methods For reliability, we evaluated the FCI’s intraclass correlation coefficient (ICC) among trained research staff performing data collection for 421 acute lung injury patients enrolled in a prospective cohort study. For validity and accuracy, we compared the detection of FCI comorbidities across three types of inpatient medical records, and the association of the respective FCI scores obtained with patients’ SF-36 physical function subscale (PFS) scores at 1-year follow-up. Results Inter-rater reliability was near-perfect (ICC 0.91; 95% CI 0.89-0.94). Hospital admission records and discharge summaries (vs. complete chart review) significantly underestimated the total FCI score. However, using multivariable linear regression, FCI scores collected using each of the three types of inpatient medical records had similar associations with PFS, suggesting similar predictive value. Conclusions Data collection using in-patient discharge summaries represents a reliable and valid method for collecting FCI comorbidity information.
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Affiliation(s)
- Eddy Fan
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA.
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231
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PET imaging of lung inflammation with [18F]FEDAC, a radioligand for translocator protein (18 kDa). PLoS One 2012; 7:e45065. [PMID: 22984611 PMCID: PMC3440397 DOI: 10.1371/journal.pone.0045065] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Accepted: 08/14/2012] [Indexed: 12/02/2022] Open
Abstract
Purpose The translocator protein (18 kDa) (TSPO) is highly expressed on the bronchial and bronchiole epithelium, submucosal glands in intrapulmonary bronchi, pneumocytes and alveolar macrophages in human lung. This study aimed to perform positron emission tomography (PET) imaging of lung inflammation with [18F]FEDAC, a specific TSPO radioligand, and to determine cellular sources enriching TSPO expression in the lung. Methods An acute lung injury model was prepared by intratracheal administration of lipopolysaccharide (LPS) to rat. Uptake of radioactivity in the rat lungs was measured with small-animal PET after injection of [18F]FEDAC. Presence of TSPO was examined in the lung tissue using Western blot and immunohistochemical assays. Results The uptake of [18F]FEDAC increased in the lung with the progress of inflammation by treatment with LPS. Pretreatment with a TSPO-selective ligand PK11195 showed a significant decrease in the lung uptake of [18F]FEDAC due to competitive binding to TSPO. TSPO expression was elevated in the inflamed lung section and its level responded to the [18F]FEDAC uptake and severity of inflammation. Increase of TSPO expression was mainly found in the neutrophils and macrophages of inflamed lungs. Conclusion From this study we conclude that PET with [18F]FEDAC may be a useful tool for imaging TSPO expression and evaluating progress of lung inflammation. Study on human lung using [18F]FEDAC-PET is promising.
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232
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Elie-Turenne MC, Hou PC, Mitani A, Barry JM, Kao EY, Cohen JE, Frendl G, Gajic O, Gentile NT. Lung injury prediction score for the emergency department: first step towards prevention in patients at risk. Int J Emerg Med 2012; 5:33. [PMID: 22943391 PMCID: PMC3598475 DOI: 10.1186/1865-1380-5-33] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 08/14/2012] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Early identification of patients at risk of developing acute lung injury (ALI) is critical for potential preventive strategies. We aimed to derive and validate an acute lung injury prediction score (EDLIPS) in a multicenter sample of emergency department (ED) patients. METHODS We performed a subgroup analysis of 4,361 ED patients enrolled in the previously reported multicenter observational study. ED risk factors and conditions associated with subsequent ALI development were identified and included in the EDLIPS model. Scores were derived and validated using logistic regression analyses. The model was assessed with the area under the receiver-operating curve (AUC) and compared to the original LIPS model (derived from a population of elective high-risk surgical and ED patients) and the Acute Physiology and Chronic Health Evaluation (APACHE II) score. RESULTS The incidence of ALI was 7.0% (303/4361). EDLIPS discriminated patients who developed ALI from those who did not with an AUC of 0.78 (95% CI 0.75, 0.82), better than the APACHE II AUC 0.70 (p ≤ 0.001) and similar to the original LIPS score AUC 0.80 (p = 0.07). At an EDLIPS cutoff of 5 (range -0.5, 15) positive and negative likelihood ratios (95% CI) for ALI development were 2.74 (2.43, 3.07) and 0.39 (0.30, 0.49), respectively, with a sensitivity 0.72(0.64, 0.78), specificity 0.74 (0.72, 0.76), and positive and negative predictive value of 0.18 (0.15, 0.21) and 0.97 (0.96, 0.98). CONCLUSION EDLIPS may help identify patients at risk for ALI development early in the course of their ED presentation. This novel model may detect at-risk patients for treatment optimization and identify potential patients for ALI prevention trials.
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Affiliation(s)
- Marie-Carmelle Elie-Turenne
- Department of Emergency Medicine, University of Florida College of Medicine, PO Box 100186, 1329 SW 16th Street, Gainesville, FL 32610, USA
- Emergency Department, Shands University of Florida Medical Center, Gainesville, FL, USA
| | - Peter C Hou
- Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
- Division of Burn, Trauma, and Surgical Critical Care, Brigham and Women’s Hospital, Boston, MA, USA
- Surgical Intensive Care Unit Translational Research (STAR) Center, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Department of Emergency Medicine & Division of Burn, Trauma, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, 75 Francis Street, Neville House 312-B, Boston, MA 02115, USA
| | - Aya Mitani
- Surgical Intensive Care Unit Translational Research (STAR) Center, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Medicine, Stanford Hospitals and Clinincs, 300 Pasteur Drive, Room: S102, MC: 5110, Stanford, CA 94305, USA
| | - Jonathan M Barry
- Division of Burn, Trauma, and Surgical Critical Care, Brigham and Women’s Hospital, Boston, MA, USA
- Surgical Intensive Care Unit Translational Research (STAR) Center, Brigham and Women’s Hospital, Boston, MA, USA
| | - Erica Y Kao
- Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
- Surgical Intensive Care Unit Translational Research (STAR) Center, Brigham and Women’s Hospital, Boston, MA, USA
- F. Edward Hebert School of Medicine, Uniform Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814-4712, USA
| | - Jason E Cohen
- Department of Emergency Medicine, Albany Medical Center, Albany, NY, USA
- Albany Medical College, Albany, NY, USA
- Albany Medical Center Emergency Medicine Group, 47 New Scotland Avenue, MC 139, Albany, NY 12208, USA
| | - Gyorgy Frendl
- Surgical Intensive Care Unit Translational Research (STAR) Center, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Department of Emergency Medicine & Division of Burn, Trauma, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, 75 Francis Street, Neville House 312-B, Boston, MA 02115, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Anesthesiology Perioperative and Pain Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Ognjen Gajic
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN, USA
- Mayo Medical School, Rochester, MA, USA
- Mayo Clinic, Pulmonary and Critical Care Medicine, Old Marian Hall, Second Floor, Room 115, 200 First St. SW, Rochester, MN 5590, USA
| | - Nina T Gentile
- Department of Emergency Medicine, Temple School of Medicine, Philadelphia, PA, USA
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233
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Bakowitz M, Bruns B, McCunn M. Acute lung injury and the acute respiratory distress syndrome in the injured patient. Scand J Trauma Resusc Emerg Med 2012; 20:54. [PMID: 22883052 PMCID: PMC3518173 DOI: 10.1186/1757-7241-20-54] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 06/11/2012] [Indexed: 12/27/2022] Open
Abstract
Acute lung injury and acute respiratory distress syndrome are clinical entities of multi-factorial origin frequently seen in traumatically injured patients requiring intensive care. We performed an unsystematic search using PubMed and the Cochrane Database of Systematic Reviews up to January 2012. The purpose of this article is to review recent evidence for the pathophysiology and the management of acute lung injury/acute respiratory distress syndrome in the critically injured patient. Lung protective ventilation remains the most beneficial therapy. Future trials should compare intervention groups to controls receiving lung protective ventilation, and focus on relevant outcome measures such as duration of mechanical ventilation, length of intensive care unit stay, and mortality.
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Affiliation(s)
- Magdalena Bakowitz
- Department of Anesthesiology & Critical Care, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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234
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Schenk P, Warszawska J, Fuhrmann V, König F, Madl C, Ratheiser K. Health-related quality of life of long-term survivors of intensive care: changes after intensive care treatment. Experience of an Austrian intensive care unit. Wien Klin Wochenschr 2012; 124:624-32. [PMID: 22875391 DOI: 10.1007/s00508-012-0224-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 07/09/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of the study was to determine if health-related quality of life of long-term survivors changes 24 months after intensive care treatment compared to the quality of life before admission. METHODS From 281 patients treated at the ICU in 2001, 132 survivors were contacted by phone on average 24 months after discharge. Fernandez questionnaire was used to assess preadmission quality of life prospectively and postdischarge quality of life, retrospectively. In addition, age, sex, admission diagnosis, ICU length of stay, presence of organ failure, and necessity of mechanical ventilation were determined. RESULTS In the 101 ICU survivors who responded to the questionnaire, the total score of quality of life did not change significantly over time (5.48 ± 5.3 before admission vs. 5.6 ± 5.8 at follow-up; p = 0.9). Similarly, the performance of normal daily activities did not alter (3.0 ± 3.5 vs. 3.39 ± 3.6; p = 0,3). In contrast, the ability to perform basic physiological activities worsened significantly (0.39 ± 0.76 vs. 0.76 ± 1.52; p = 0.037), whereas the emotional state improved significantly after intensive care treatment (2.08 ± 1.78 vs. 1.46 ± 1.56, p = 0.003). In a stepwise multiple regression analysis the total score of quality of life before admission was the only variable which influenced the quality of life 2 years after ICU-stay. CONCLUSIONS In the interviewed population the total score of health-related quality of life did not change after intensive care treatment. Surprisingly, emotional state improved significantly although physical performance decreased. Quality of life after ICU discharge was predominantly influenced by preadmission quality of life. However, these results are not reflective of all ICU survivors.
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Affiliation(s)
- Peter Schenk
- Department of Pulmonology, Landesklinikum Thermenregion Hochegg, Hocheggerstrasse 88, 2840, Grimmenstein, Austria.
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235
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Abstract
PURPOSE OF REVIEW Recovery and rehabilitation after critical illness is a vital part of intensive care management. The role of feeding and nutritional intervention is the subject of many recent studies. The gastric hormone ghrelin has effects on appetite and food intake and on immunomodulatory functions. Here we review the interactions between critical illness, appetite regulation, nutrition and ghrelin. RECENT FINDINGS Critical illness results in significant loss of lean body mass; strategies to prevent this have so far proven unsuccessful. Ghrelin has been shown to reduce catabolic protein loss in animal models of critical illness and improve body composition in chronic cachectic illnesses in humans. SUMMARY Enhancing recovery from critical illness will improve both short-term and long-term outcomes. Ghrelin may offer an important means of improving appetite, muscle mass and rehabilitation in the period after critical illness, although studies are needed to see whether this potential is realized.
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236
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Connolly B, Denehy L, Brett S, Elliott D, Hart N. Exercise rehabilitation following hospital discharge in survivors of critical illness: an integrative review. Crit Care 2012; 16:226. [PMID: 22713336 PMCID: PMC3580599 DOI: 10.1186/cc11219] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Although clinical trials have shown benefit from early rehabilitation within the ICU, rehabilitation of patients following critical illness is increasingly acknowledged as an area of clinical importance. However, despite recommendations from published guidelines for rehabilitation to continue following hospital discharge, there is limited evidence to underpin practice during this intermediate stage of recovery. Those patients with ICU-acquired weakness on discharge from the ICU are most likely to benefit from ongoing rehabilitation. Despite this, screening based on strength alone may fail to account for the associated level of physical functioning, which may not correlate with muscle strength, nor address non-physical complications of critical illness. The aim of this review was to consider which patients are likely to require rehabilitation following critical illness and to perform an integrative review of the available evidence of content and nature of exercise rehabilitation programmes for survivors of critical illness following hospital discharge. Literature databases and clinical trials registries were searched using appropriate terms and groups of terms. Inclusion criteria specified the reporting of rehabilitation programmes for patients following critical illness post-hospital discharge. Ten items, including data from published studies and protocols from trial registries, were included. Because of the variability in study methodology and inadequate level of detail of reported exercise prescription, at present there can be no clear recommendations for clinical practice from this review. As this area of clinical practice remains in its relative infancy, further evidence is required both to identify which patients are most likely to benefit and to determine the optimum content and format of exercise rehabilitation programmes for patients following critical illness post-hospital discharge.
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Affiliation(s)
- Bronwen Connolly
- Department of Asthma, Allergy and Respiratory Science, Division of Asthma, Allergy and Lung Biology, King's College London, London SE1 9RT, UK
- Guy's and St Thomas' NHS Foundation Trust and King's College London, National Institute of Health Research Comprehensive Biomedical Research Centre, London SE1 9RT, UK
| | - Linda Denehy
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Melbourne, 3010 Australia
| | - Stephen Brett
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Doug Elliott
- Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, Sydney, 2007 Australia
| | - Nicholas Hart
- Department of Asthma, Allergy and Respiratory Science, Division of Asthma, Allergy and Lung Biology, King's College London, London SE1 9RT, UK
- Guy's and St Thomas' NHS Foundation Trust and King's College London, National Institute of Health Research Comprehensive Biomedical Research Centre, London SE1 9RT, UK
- Lane Fox Respiratory Unit, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
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237
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Understanding health economic analysis in critical care: insights from recent randomized controlled trials. Curr Opin Crit Care 2012; 17:504-9. [PMID: 21900769 DOI: 10.1097/mcc.0b013e32834a4bc1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The article reviews the methods of health economic analysis (HEA) in clinical trials of critically ill patients. Emphasis is placed on the usefulness of HEA in the context of positive and 'no effect' studies, with recent examples. RECENT FINDINGS The need to control costs and promote effective spending in caring for the critically ill has garnered considerable attention due to the high cost of critical illness. Many clinical trials focus on short-term mortality, ignoring costs and quality of life, and fail to change clinical practice or promote efficient use of resources. Incorporating HEA into clinical trials is a possible solution. Such studies have shown some interventions, although expensive, provide good value, whereas others should be withdrawn from clinical practice. Incorporating HEA into randomized controlled trials (RCTs) requires careful attention to collect all relevant costs. Decision trees, modeling assumptions and methods for collecting costs and measuring outcomes should be planned and published beforehand to minimize bias. SUMMARY Costs and cost-effectiveness are potentially useful outcomes in RCTs of critically ill patients. Future RCTs should incorporate parallel HEA to provide both economic outcomes, which are important to the community, alongside patient-centered outcomes, which are important to individuals.
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238
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Iwashyna TJ, Netzer G, Langa KM, Cigolle C. Spurious inferences about long-term outcomes: the case of severe sepsis and geriatric conditions. Am J Respir Crit Care Med 2012; 185:835-41. [PMID: 22323301 DOI: 10.1164/rccm.201109-1660oc] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
RATIONALE Survivors of critical illness suffer significant limitations and disabilities. OBJECTIVES Ascertain whether severe sepsis is associated with increased risk of so-called geriatric conditions (injurious falls, low body mass index [BMI], incontinence, vision loss, hearing loss, and chronic pain) and whether this association is measured consistently across three different study designs. METHODS Patients with severe sepsis were identified in the Health and Retirement Study, a nationally representative cohort interviewed every 2 years, 1998 to 2006, and in linked Medicare claims. Three comparators were used to assess an association of severe sepsis with geriatric conditions in survivors: the prevalence in the United States population aged 65 years and older, survivors' own pre-sepsis levels assessed before hospitalization, or survivors' own pre-sepsis trajectory. MEASUREMENTS AND MAIN RESULTS Six hundred twenty-three severe sepsis hospitalizations were followed a median of 0.92 years. When compared with the 65 years and older population, surviving severe sepsis was associated with increased rates of low BMI, injurious falls, incontinence, and vision loss. Results were similar when comparing survivors to their own pre-sepsis levels. The association of low BMI and severe sepsis persisted when controlling for patients' pre-sepsis trajectories, but there was no association of severe sepsis with injurious falls, incontinence, vision loss, hearing loss, and chronic pain after such controls. CONCLUSIONS Geriatric conditions are common after severe sepsis. However, severe sepsis is associated with increased rates of only a subset of geriatric conditions, not all. In studying outcomes after acute illness, failing to measure and control for both preillness levels and trajectories may result in erroneous conclusions.
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Tulapurkar ME, Almutairy EA, Shah NG, He JR, Puche AC, Shapiro P, Singh IS, Hasday JD. Febrile-range hyperthermia modifies endothelial and neutrophilic functions to promote extravasation. Am J Respir Cell Mol Biol 2012; 46:807-14. [PMID: 22281986 DOI: 10.1165/rcmb.2011-0378oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a neutrophil (polymorphonuclear leukocyte; PMN)-driven lung injury that is associated with fever and heat-stroke, and involves approximately 40% mortality. In murine models of acute lung injury (ALI), febrile-range hyperthermia (FRH) enhanced PMN accumulation, vascular permeability, and epithelial injury, in part by augmenting pulmonary cysteine-x-cysteine (CXC) chemokine expression. To determine whether FRH increases chemokine responsiveness within the lung, we used in vivo and in vitro models that bypass the endogenous generation of chemokines. We measured PMN transalveolar migration (TAM) in mice after intratracheal instillations of the human CXC chemokine IL-8 in vivo, and of IL-8-directed PMN transendothelial migration (TEM) through human lung microvascular endothelial cell (HMVEC-L) monolayers in vitro. Pre-exposure to FRH increased in vivo IL-8-directed PMN TAM by 23.5-fold and in vitro TEM by 7-fold. Adoptive PMN transfer demonstrated that enhanced PMN TAM required both PMN donors and recipients to be exposed to FRH, suggesting interdependent effects on PMNs and endothelium. FRH exposure caused the activation of extracellular signal-regulated kinase (ERK) and p38 mitogen-activated protein kinase in lung homogenates and circulating PMNs, with an associated increase in HSP27 phosphorylation and stress-fiber formation. The inhibition of these signaling pathways with U0126 and SB203580 blocked the effects of FRH on PMN extravasation in vivo and in vitro. Collectively, these results (1) demonstrate that FRH augments chemokine-directed PMN extravasation through direct effects on endothelium and PMNs, (2) identify ERK and p38 signaling pathways in the effect, and (3) underscore the complex effects of physiologic temperature change on innate immune function and its potential consequences for lung injury.
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Affiliation(s)
- Mohan E Tulapurkar
- Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, University of Maryland, 20 Penn St., Baltimore, MD 21201, USA
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Physical function, disability and rehabilitation in the elderly critically ill. RÉFÉRENCES EN RÉANIMATION. COLLECTION DE LA SRLF 2012. [DOI: 10.1007/978-2-8178-0287-9_12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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241
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Parry SM, Berney S, Koopman R, Bryant A, El-Ansary D, Puthucheary Z, Hart N, Warrillow S, Denehy L. Early rehabilitation in critical care (eRiCC): functional electrical stimulation with cycling protocol for a randomised controlled trial. BMJ Open 2012; 2:bmjopen-2012-001891. [PMID: 22983782 PMCID: PMC3467594 DOI: 10.1136/bmjopen-2012-001891] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Intensive care-acquired weakness is a common problem, leads to significant impairment in physical functioning and muscle strength, and is prevalent in individuals with sepsis. Early rehabilitation has been shown to be safe and feasible; however, commencement is often delayed due to a patient's inability to co-operate. An intervention that begins early in an intensive care unit (ICU) admission without the need for patient volition may be beneficial in attenuating muscle wasting. The eRiCC (early rehabilitation in critical care) trial will investigate the effectiveness of functional electrical stimulation-assisted cycling and cycling alone, compared to standard care, in individuals with sepsis. METHODS AND ANALYSIS This is a single centre randomised controlled trial. Participants (n=80) aged ≥18 years, with a diagnosis of sepsis or severe sepsis, who are expected to be mechanically ventilated for ≥48 h and remain in the intensive care ≥4 days will be randomised within 72 h of admission to (1) standard care or (2) intervention where participants will receive functional electrical muscle stimulation-assisted supine cycling on one leg while the other leg undergoes cycling alone. Primary outcome measures include: muscle mass (quadriceps ultrasonography; bioelectrical impedance spectroscopy); muscle strength (Medical Research Council Scale; hand-held dynamometry) and physical function (Physical Function in Intensive Care Test; Functional Status Score in intensive care; 6 min walk test). Blinded outcome assessors will assess measures at baseline, weekly, at ICU discharge and acute hospital discharge. Secondary measures will be evaluated in a nested subgroup (n=20) and will consist of biochemical/histological analyses of collected muscle, urine and blood samples at baseline and at ICU discharge. ETHICS AND DISSEMINATION Ethics approval has been obtained from the relevant institution, and results will be published to inform clinical practice in the care of patients with sepsis to optimise rehabilitation and physical function outcomes. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry ACTRN12612000528853.
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Affiliation(s)
- Selina M Parry
- Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Melbourne, Australia
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242
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Chiumello D, Taccone P, Berto V, Marino A, Migliara G, Lazzerini M, Gattinoni L. Long-term outcomes in survivors of acute respiratory distress syndrome ventilated in supine or prone position. Intensive Care Med 2011; 38:221-9. [PMID: 22187085 DOI: 10.1007/s00134-011-2445-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 10/25/2011] [Indexed: 12/29/2022]
Abstract
PURPOSE The aim of this study is to examine long-term pulmonary function and quality of life in survivors of acute respiratory distress syndrome (ARDS) previously enrolled in a randomized multicenter trial testing prone compared with supine positioning (PSII study) at five Italian centers. DESIGN Observational prospective study. SUBJECTS AND MEASUREMENTS Pulmonary function [spirometric test, gas exchange, carbon monoxide diffusion capacity (DLCO)], high-resolution computed tomography (CT) scan, and health-related quality of life [Short Form-36 (SF-36) and St. George's Respiratory Questionnaire] were evaluated at 12 months. RESULTS Twenty-six patients (13 in each group, mean age 54.1 ± 2.8 years, body mass index 24.5 ± 1.4 kg/m(2), PaO(2)/FiO(2) 117 ± 49 mmHg) were evaluated. There were no significant differences in demographic data, illness severity, or outcome between the prone and supine groups. The overall survival rate was 40%. Pulmonary function was in the normal range without any differences between the two groups. Quantitative lung CT scan analysis showed similar amounts for not aerated (8.1 ± 3.2% versus 7.3 ± 3.4%), poorly aerated (15.3 ± 3.6% versus 17.1 ± 4.9%), and well-aerated (64.0% ± 8.4 versus 70.2 ± 8.4%) lung regions, while overaerated lung region was slightly higher in the prone compared with the supine group (12.5 ± 6.5% versus 5.3 ± 5.5%). Health-related quality of life was similar to in healthy population. However, these patients showed reduction in daily activity specifically due to pulmonary disease as measured by the St. George's Respiratory Questionnaire. CONCLUSIONS No differences in pulmonary function or quality of life were observed in this small group of ARDS survivor patients treated in prone versus supine position.
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Affiliation(s)
- D Chiumello
- Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milan, Italy.
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243
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Abstract
Interest in longer-term outcomes after acute respiratory distress syndrome (ARDS) and the understanding of patterns of recovery have increased enormously over the past 10 years. This article highlights important advances in outcomes after ARDS and describes pulmonary outcomes, the most recent data on functional and neuropsychological disability in patients, health care cost, family caregivers, and early models of rehabilitation and intervention.
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Affiliation(s)
- Margaret S Herridge
- Division of Respiratory and Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, 11C-1180 585 University Avenue, Toronto, Ontario M5G 2C4, Canada.
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244
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Proudfoot AG, Hind M, Griffiths MJD. Biomarkers of acute lung injury: worth their salt? BMC Med 2011; 9:132. [PMID: 22152131 PMCID: PMC3261814 DOI: 10.1186/1741-7015-9-132] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 12/12/2011] [Indexed: 12/21/2022] Open
Abstract
The validation of biomarkers has become a key goal of translational biomedical research. The purpose of this article is to discuss the role of biomarkers in the management of acute lung injury (ALI) and related research. Biomarkers should be sensitive and specific indicators of clinically important processes and should change in a relevant timeframe to affect recruitment to trials or clinical management. We do not believe that they necessarily need to reflect pathogenic processes. We critically examined current strategies used to identify biomarkers and which, owing to expedience, have been dominated by reanalysis of blood derived markers from large multicenter Phase 3 studies. Combining new and existing validated biomarkers with physiological and other data may add predictive power and facilitate the development of important aids to research and therapy.
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Affiliation(s)
- Alastair G Proudfoot
- Royal Brompton & Harefield NHS Foundation Trust, Adult Intensive Care Unit, Sydney Street, London SW3 6NP, UK
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245
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Bienvenu OJ, Colantuoni E, Mendez-Tellez PA, Dinglas VD, Shanholtz C, Husain N, Dennison CR, Herridge MS, Pronovost PJ, Needham DM. Depressive symptoms and impaired physical function after acute lung injury: a 2-year longitudinal study. Am J Respir Crit Care Med 2011; 185:517-24. [PMID: 22161158 DOI: 10.1164/rccm.201103-0503oc] [Citation(s) in RCA: 169] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Survivors of acute lung injury (ALI) frequently have substantial depressive symptoms and physical impairment, but the longitudinal epidemiology of these conditions remains unclear. OBJECTIVES To evaluate the 2-year incidence and duration of depressive symptoms and physical impairment after ALI, as well as risk factors for these conditions. METHODS This prospective, longitudinal cohort study recruited patients from 13 intensive care units (ICUs) in four hospitals, with follow-up 3, 6, 12, and 24 months after ALI. The outcomes were Hospital Anxiety and Depression Scale depression score greater than or equal to 8 ("depressive symptoms") in patients without a history of depression before ALI, and two or more dependencies in instrumental activities of daily living ("impaired physical function") in patients without baseline impairment. MEASUREMENTS AND MAIN RESULTS During 2-year follow-up of 186 ALI survivors, the cumulative incidences of depressive symptoms and impaired physical function were 40 and 66%, respectively, with greatest incidence by 3-month follow-up; modal durations were greater than 21 months for each outcome. Risk factors for incident depressive symptoms were education 12 years or less, baseline disability or unemployment, higher baseline medical comorbidity, and lower blood glucose in the ICU. Risk factors for incident impaired physical function were longer ICU stay and prior depressive symptoms. CONCLUSIONS Incident depressive symptoms and impaired physical function are common and long-lasting during the first 2 years after ALI. Interventions targeting potentially modifiable risk factors (e.g., substantial depressive symptoms in early recovery) should be evaluated to improve ALI survivors' long-term outcomes.
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Affiliation(s)
- Oscar J Bienvenu
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Jackson JC, Mitchell N, Hopkins RO. Cognitive functioning, mental health, and quality of life in ICU survivors: an overview. Anesthesiol Clin 2011; 29:751-764. [PMID: 22078921 DOI: 10.1016/j.anclin.2011.09.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The significant and sometimes permanent effects of critical illness on wide-ranging aspects of functioning are increasingly recognized. Among the areas affected are acute and long-term cognitive functioning, depression, anxiety, PTSD, and quality of life. These and other areas are increasingly being studied and indeed are increasingly the focus of clinical attention and investigations. These conditions have been a focus of attention for more than a dozen years, with much improvement occurring in the ability to characterize these phenomena. For instance, in intervening years, it has been learned that cognitive impairment is highly prevalent and functionally disruptive and that it occurs in wide-ranging domains. Key questions remain unanswered with regard to vital questions such as determining causes, risk factors, and mechanisms as well as the degree to which brain injuries associated with critical illness are amenable to rehabilitation. Little remains known about the effects of critical illness on elderly ICU cohorts and on the neurologic functioning of individuals with preexisting impairment versus those who are normal. Few data exist regarding the development of strategies designed to prevent the emergence of neuropsychological deficits after critical illness. Although great progress has been made and is ongoing, a pressing need exists for additional investigation of cognitive impairment and other conditions,such as PTSD and quality of life after critical illness, that will seek to untangle the many pertinent questions related to this condition and that will ultimately offer help and hope to the thousands of survivors affected by this condition.
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Affiliation(s)
- James C Jackson
- Center for Health Services Research, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, 6th Floor MCE Suite 6100, Nashville, TN 37232, USA
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247
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Wilcox ME, Herridge MS. Lung function and quality of life in survivors of the acute respiratory distress syndrome (ARDS). Presse Med 2011; 40:e595-603. [PMID: 22078086 DOI: 10.1016/j.lpm.2011.04.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Accepted: 04/29/2011] [Indexed: 11/26/2022] Open
Abstract
Recent studies have begun to describe the long-term outcomes of acute respiratory distress syndrome (ARDS) survivors. These patients experience a number of physical, mental and psychological morbidities that significantly impair their health-related quality of life (HRQL). The trajectory of pulmonary recovery in survivors of ARDS, as it relates to lung function, structure and health-related quality of life (HRQL), is predictable and often persists years after hospital discharge. True pulmonary parenchymal morbidity is uncommon and when present, persistent restrictive disease is likely related to diaphragmatic weakness with a mild reduction in diffusion capacity (DLCO). Future research should focus on identifying patients at risk for long-term functional limitations and the design of rehabilitation interventions tailored to individual patient needs.
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Affiliation(s)
- M Elizabeth Wilcox
- University of Toronto, Toronto Western Hospital, Division of Pulmonary and Critical Care Medicine, Toronto, Ontario, Canada.
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Adhikari NKJ, Tansey CM, McAndrews MP, Matté A, Pinto R, Cheung AM, Diaz-Granados N, Herridge MS. Self-reported depressive symptoms and memory complaints in survivors five years after ARDS. Chest 2011; 140:1484-1493. [PMID: 21998261 DOI: 10.1378/chest.11-1667] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Survivors of ARDS report depressive symptoms and memory complaints, the prevalence of which after 5 years is unknown. METHODS We administered instruments assessing symptoms of depression (Beck Depression Inventory II [BDI-II]) and memory complaints (Memory Assessment Clinics Self-Rating Scale [MAC-S]) to 64 survivors of ARDS from four university-affiliated ICUs 5 years after ICU discharge. We compared BDI-II scores to quality of life (Medical Outcomes Study 36-Item Short Form [SF-36]) mental health domains (role emotional, mental health, mental component summary), compared BDI-II and MAC-S scores to earlier scores (median, 22 months postdischarge), and examined return to work. RESULTS Forty-three (67.2%), 46 (71.9%), and 38 (59.4%) patients fully completed the BDI-II, MAC-S ability subscale, and MAC-S frequency of occurrence subscale, respectively. Responders were young (median, 48 years; first-third quartile [Q1-Q3], 39-61 years) with high illness severity. The median BDI-II score was 10 (Q1-Q3, 3-18); eight of 43 (18.6%) had moderate to severe depressive symptoms compared with 14 of 43 (32.6%) earlier (P = .15, n = 38 with paired data). Median MAC-S ability and MAC-S frequency scores were 81 (Q1-Q3, 57-92) and 91.5 (Q1-Q3, 76-105), respectively, similar to earlier scores (P = .67 and P = .64, respectively); 0% to 4.3% scored > 2 SDs below population norms. Higher BDI-II score was predicted by higher earlier BDI-II score, slower recovery of organ function, and longer duration of mechanical ventilation and ICU stay. Higher MAC-S score was predicted by higher earlier MAC-S score. SF-36 mental health domain scores were very stable (P = .57-.83). BDI-II and SF-36 mental health domains were negatively correlated (Spearman coefficient, -0.50 to -0.82). Most patients returned to work regardless of depressive symptoms (minimal to mild, 31 of 35 [88.6%]; moderate to severe, five of eight [62.5%]; P = .12). CONCLUSIONS Compared with ∼ 2 years postdischarge from the ICU, depressive symptoms and memory complaints were similar at 5 years. Mental health domains of the SF-36 may not be sensitive to small changes in mood symptoms.
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Affiliation(s)
- Neill K J Adhikari
- Interdepartmental Division of Critical Care, University of Toronto, Toronto; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto.
| | | | | | - Andrea Matté
- Department of Medicine, University Health Network, Toronto
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto
| | - Angela M Cheung
- Department of Medicine, University Health Network, Toronto; Women's Health Program, University Health Network, Toronto; Department of Medicine, University of Toronto, Toronto; Department of Health Policy, Management and Evaluation and the Dalla Lana School of Public Health, University of Toronto, Toronto
| | - Natalia Diaz-Granados
- Women's Health Program, University Health Network, Toronto; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care, University of Toronto, Toronto; Department of Medicine, University Health Network, Toronto; Department of Medicine, University of Toronto, Toronto
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Clermont G, Kong L, Weissfeld LA, Lave JR, Rubenfeld GD, Roberts MS, Connors AF, Bernard GR, Thompson BT, Wheeler AP, Angus DC. The effect of pulmonary artery catheter use on costs and long-term outcomes of acute lung injury. PLoS One 2011; 6:e22512. [PMID: 21811626 PMCID: PMC3141060 DOI: 10.1371/journal.pone.0022512] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 06/27/2011] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The pulmonary artery catheter (PAC) remains widely used in acute lung injury (ALI) despite known complications and little evidence of improved short-term mortality. Concurrent with NHLBI ARDS Clinical Trials Network Fluid and Catheters Treatment Trial (FACTT), we conducted a prospectively-defined comparison of healthcare costs and long-term outcomes for care with a PAC vs. central venous catheter (CVC). We explored if use of the PAC in ALI is justified by a beneficial cost-effectiveness profile. METHODS We obtained detailed bills for the initial hospitalization. We interviewed survivors using the Health Utilities Index Mark 2 questionnaire at 2, 6, 9 and 12 m to determine quality of life (QOL) and post-discharge resource use. Outcomes beyond 12 m were estimated from federal databases. Incremental costs and outcomes were generated using MonteCarlo simulation. RESULTS Of 1001 subjects enrolled in FACTT, 774 (86%) were eligible for long-term follow-up and 655 (85%) consented. Hospital costs were similar for the PAC and CVC groups ($96.8k vs. $89.2k, p = 0.38). Post-discharge to 12 m costs were higher for PAC subjects ($61.1k vs. 45.4k, p = 0.03). One-year mortality and QOL among survivors were similar in PAC and CVC groups (mortality: 35.6% vs. 31.9%, p = 0.33; QOL [scale: 0-1]: 0.61 vs. 0.66, p = 0.49). MonteCarlo simulation showed PAC use had a 75.2% probability of being more expensive and less effective (mean cost increase of $14.4k and mean loss of 0.3 quality-adjusted life years (QALYs)) and a 94.2% probability of being higher than the $100k/QALY willingness-to-pay threshold. CONCLUSION PAC use increased costs with no patient benefit and thus appears unjustified for routine use in ALI. TRIAL REGISTRATION www.clinicaltrials.gov NCT00234767.
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Affiliation(s)
- Gilles Clermont
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.
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Williams TA, Leslie GD. Challenges and possible solutions for long-term follow-up of patients surviving critical illness. Aust Crit Care 2011; 24:175-85. [PMID: 21514838 DOI: 10.1016/j.aucc.2011.03.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 03/17/2011] [Accepted: 03/23/2011] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Surviving critical illness can be life-changing and present new healthcare challenges for patients after discharge from hospital. Optimisation of recovery, rather than mere survival, is an important goal of intensive care. Observational studies have identified decreased quality of life and increased healthcare needs for survivors but loss to follow-up can be high with possible selection bias. Patients in need of support may therefore not be included in study results or allocated appropriate follow up support. AIM To examine the frequency and reasons patients admitted to general ICUs who survive critical illness are excluded from study participation or lost to follow-up and consider the possible implications and solutions. METHOD The literature review included searches of the MEDLINE, EMBASE, and CINAHL databases. Studies (2006-2010) were included if they described follow-up of survivors from general ICUs. RESULTS Ten studies were reviewed. Of the 3269 eligible patients, 14% died after hospital discharge, 27% declined, and 22% were lost to follow-up. Reasons for loss to follow-up included no response, inability to contact the patient, too ill or admitted to another facility. CONCLUSION The most appropriate method of care follow-up has yet to be established but is likely to involve an eclectic model that tailors service provision to support individual patient needs. Identifying methods to minimise loss to follow-up may enhance interpretation of patients' recovery, lead to improvements in clinical practice and inform healthcare service decisions and policy.
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Affiliation(s)
- Teresa A Williams
- School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, Western Australia, Australia.
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