401
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Claydon J, Maniatopoulos G, Robinson L, Fearon P. Challenges experienced during rehabilitation after traumatic multiple rib fractures: a qualitative study. Disabil Rehabil 2017; 40:2780-2789. [DOI: 10.1080/09638288.2017.1358771] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Jacqueline Claydon
- Major Trauma Rehabilitation Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Lisa Robinson
- Major Trauma Rehabilitation Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Paul Fearon
- Department of Trauma and Orthopaedics, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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402
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Caprarola SD, Kudchadkar SR, Bembea MM. Neurologic Outcomes Following Care in the Pediatric Intensive Care Unit. ACTA ACUST UNITED AC 2017; 3:193-207. [PMID: 29218262 DOI: 10.1007/s40746-017-0092-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Purpose of review With increasing survival of children requiring admission to pediatric intensive care units (PICU), neurodevelopmental outcomes of these patients are an area of increased attention. Our goal was to systematically review recently published literature on neurologic outcomes of PICU patients. Recent Findings Decline in neurofunctional status occurs in 3%-20% of children requiring PICU care. This proportion varies based on primary diagnosis and severity of illness, with children admitted for primary neurologic diagnosis, children who suffer cardiac arrest or who require invasive interventions during the PICU admission, having worse outcomes. Recent research focuses on early identification and treatment of modifiable risk factors for unfavorable outcomes, and on long-term follow-up that moves beyond global cognitive outcomes and is increasingly including tests assessing multidimensional aspects of neurodevelopment. Summary The pediatric critical care research community has shifted focus from survival to survival with favorable neurologic outcomes of children admitted to the PICU.
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Affiliation(s)
- Sherrill D Caprarola
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, 6621 Fannin St, Houston, TX, United States, 77030
| | - Sapna R Kudchadkar
- Departments of Anesthesiology and Critical Care Medicine, and Pediatrics, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, United States, 21287
| | - Melania M Bembea
- Departments of Anesthesiology and Critical Care Medicine, and Pediatrics, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, United States, 21287
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403
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Burns KEA, Devlin JW, Hill NS. Patient and Family Engagement in Designing and Implementing a Weaning Trial: A Novel Research Paradigm in Critical Care. Chest 2017; 152:707-711. [PMID: 28687380 DOI: 10.1016/j.chest.2017.06.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 06/19/2017] [Indexed: 11/18/2022] Open
Abstract
The call for meaningful patient and family engagement in research has recently gained considerable momentum. This article defines patient and family engagement broadly and specifically in clinical research. Using a multicenter, North American weaning trial as an exemplar, we describe our early experiences as clinical researchers with patient and family engagement. The role of our Patient and Family Advisory Committee in trial design and implementation is illustrated. Through our experiences, we share our insights regarding the perceived opportunities and also highlight some challenges associated with engaging patients and family engagement in critical care research. Although "engagement science" is in its infancy, engaging patients and families in research holds promise as a novel research paradigm that will not only provide new insights into the questions, methods, and outcomes used in ICU research, but it will also make investments in research more accountable and ensure a strong "patient- and family-centered focus" of our research.
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Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA; Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA
| | - Nicholas S Hill
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA
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404
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Acute psychological trauma in the critically ill: Patient and family perspectives. Gen Hosp Psychiatry 2017; 47:68-74. [PMID: 28807140 DOI: 10.1016/j.genhosppsych.2017.04.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 04/24/2017] [Accepted: 04/24/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Post-intensive care syndrome (PICS), which encompasses profound psychological morbidity, affects many survivors of critical illness. We hypothesize that acute psychological stress during the intensive care unit (ICU) confinement likely contributes to PICS. In order to develop strategies that mitigate PICS associated psychological morbidity, it is paramount to first characterize acute ICU psychological stress and begin to understand its causative and protective factors. METHODS A structured interview study was administered to adult critical illness survivors who received ≥48h of mechanical ventilation in medical and surgical ICUs of a tertiary care center, and their families. RESULTS Fifty patients and 44 family members were interviewed following ICU discharge. Patients reported a high level of psychological distress. The families' perception of patient's stress level correlated with the patient's self-estimated stress level both in daily life (rho=0.59; p<0.0001) and in ICU (rho=0.45; p=0.002). 70% of patients experienced fear of death, 38% had additional other fears, 48% had hallucinations. Concerns included inability to communicate (34%), environmental factors (30%), procedures and restraints (24%), and being intubated (12%). Emotional support of family/friend/staff/clergy (86%), and physical therapy/walking (14%) were perceived to be important mitigating factors. Clinicians' actions that were perceived to be very constructive included reassurance (54%), explanations (32%) and physical touch (8%). CONCLUSIONS Fear, hallucinations, and the inability to communicate, are identified as central contributors to psychological stress during an ICU stay; the presence of family, and physician's attention are categorized as important mitigating factors. Patients and families identified several practical recommendations which may help assuage the psychological burden of the ICU stay.
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405
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Günther A, Sackey P, Bjärtå A, Schandl A. The relation between skin conductance responses and recovery from symptoms of PTSD. Acta Anaesthesiol Scand 2017; 61:688-695. [PMID: 28421596 DOI: 10.1111/aas.12890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 03/03/2017] [Accepted: 03/12/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND The purpose was to investigate if potentially stressful reminders of the intensive care unit (ICU) stay influenced variability in transient skin conductance responses, and whether such changes were associated with post-traumatic stress symptoms (PTSS), and development of symptoms over time. METHODS Thirty patients with an ICU length of stay > 48 h were included in the study. Within the week after ICU discharge (T1), patients were exposed to authentic ICU sound and questions regarding traumatic ICU memories while skin conductance reactivity was monitored. PTSS was assessed using PTSS-10 at T1 and again 3 months later (T2). Changes in number of skin conductance fluctuations per second (NSCF) between baseline and during the cueing conditions and in relation to PTSS scores (T1) were investigated. PTSS scores at T2 and changes between T1 and T2 (PTSS-CS) were used to investigate if reactivity in NSCF could predict symptoms of PTSD. RESULTS The results showed increases in NSCF during both situational and verbal cueing, compared to baseline. However, no relation to PTSS scores was indicated. Negative correlations between NSCF during situational cueing and both PTSS-T2 and PTSS-CS were found among women, but not among men. CONCLUSION A low variability, or reactivity in skin conductance responses to situational cues could imply a risk of developing, or not being able to recover from, symptoms of PTSD in women. As such, the measurement could be used to predict this risk in women. However, further studies are necessary to evaluate this area of application.
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Affiliation(s)
- A. Günther
- Perioperative Medicine and Intensive care; Karolinska University Hospital Solna; Stockholm Sweden
- Department of Cardiothoracic Surgery and Anaesthesiology; Karolinska University Hospital Solna; Stockholm Sweden
| | - P. Sackey
- Perioperative Medicine and Intensive care; Karolinska University Hospital Solna; Stockholm Sweden
- Institution of Physiology and Pharmacology; Karolinska Institutet; Stockholm Sweden
| | - A. Bjärtå
- Department of Psychology; Division of Social Sciences; Mid Sweden University; Östersund Sweden
| | - A. Schandl
- Perioperative Medicine and Intensive care; Karolinska University Hospital Solna; Stockholm Sweden
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406
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407
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Battle CE, James K, Bromfield T, Temblett P. Predictors of post-traumatic stress disorder following critical illness: A mixed methods study. J Intensive Care Soc 2017; 18:289-293. [PMID: 29123558 DOI: 10.1177/1751143717713853] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Purpose Post-traumatic stress disorder has been reported in survivors of critical illness. The aim of this study was to investigate the predictors of post-traumatic stress disorder in survivors of critical illness. Materials and methods Patients attending the intensive care unit (ICU) follow-up clinic completed the UK-Post-Traumatic Stress Syndrome 14-Questions Inventory and data was collected from their medical records. Predictors investigated included age, gender, Apache II score, ICU length of stay, pre-illness psychopathology; delirium and benzodiazepine administration during ICU stay and delusional memories of the ICU stay following discharge. Results A total of 198 patients participated, with 54 (27%) patients suffering with post-traumatic stress disorder. On multivariable logistic regression, the significant predictors of post-traumatic stress disorder were younger age, lower Apache II score, pre-illness psychopathology and delirium during the ICU stay. Conclusions The predictors of post-traumatic stress disorder in this study concur with previous research however a lower Apache II score has not been previously reported.
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Affiliation(s)
- Ceri E Battle
- Ed Major Critical Care Unit, Morriston Hospital, Swansea, UK
| | - Karen James
- Ed Major Critical Care Unit, Morriston Hospital, Swansea, UK
| | - Tom Bromfield
- Ed Major Critical Care Unit, Morriston Hospital, Swansea, UK
| | - Paul Temblett
- Ed Major Critical Care Unit, Morriston Hospital, Swansea, UK
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408
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Abrahamian H, Lebherz-Eichinger D. The role of psychosomatic medicine in intensive care units. Wien Med Wochenschr 2017; 168:67-75. [PMID: 28616666 DOI: 10.1007/s10354-017-0575-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 05/19/2017] [Indexed: 12/16/2022]
Abstract
Critically ill patients, their relatives, and intensive care staff are consistently exposed to stress. The principal elements of this exceptional burden are confrontation with a life-threatening disease, specific environmental conditions at the intensive care unit, and the social characteristics of intensive care medicine. The short- and long-term consequences of these stressors include a feeling of helplessness, distress, anxiety, depression, and even posttraumatic stress disorders. Not only the patients, but also their relatives and intensive care staff are at risk of developing such psychopathologies. The integration of psychosomatic medicine into the general concept of intensive care medicine is an essential step for the early identification of fear and anxiety and for understanding biopsychosocial coherence in critically ill patients. Preventive measures such as the improvement of individual coping strategies and enhancing the individual's resistance to stress are crucial aspects of improving wellbeing, as well as the overall outcome of disease. Additional stress-reducing measures reported in the published literature, such as hearing music, the use of earplugs and eye-masks, or basal stimulation, have been successful to a greater or lesser extent.
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Affiliation(s)
- Heidemarie Abrahamian
- Department of Internal Medicine, Otto Wagner Hospital, Baumgartner Höhe 1, 1140, Vienna, Austria.
| | - Diana Lebherz-Eichinger
- Department of Internal Medicine, Otto Wagner Hospital, Baumgartner Höhe 1, 1140, Vienna, Austria
- Department of Anesthesia, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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409
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Depressive Symptoms After Critical Illness: A Systematic Review and Meta-Analysis. Crit Care Med 2017; 44:1744-53. [PMID: 27153046 DOI: 10.1097/ccm.0000000000001811] [Citation(s) in RCA: 259] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To synthesize data on prevalence, natural history, risk factors, and post-ICU interventions for depressive symptoms in ICU survivors. DATA SOURCES PubMed, EMBASE, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, and Cochrane Controlled Trials Registry (1970-2015). STUDY SELECTION Studies measuring depression after hospital discharge using a validated instrument in more than 20 adults from non-specialty ICUs. DATA EXTRACTION Duplicate independent review and data abstraction. DATA SYNTHESIS The search identified 27,334 titles, with 42 eligible articles on 38 unique studies (n = 4,113). The Hospital Anxiety and Depression Scale-Depression subscale was used most commonly (58%). The pooled Hospital Anxiety and Depression Scale-Depression subscale prevalence (95% CI) of depressive symptoms at a threshold score greater than or equal to 8 was 29% (22-36%) at 2-3 months (12 studies; n = 1,078), 34% (24-43%) at 6 months (seven studies; n = 760), and 29% (23-34%) at 12-14 months (six studies; n = 1,041). The prevalence of suprathreshold depressive symptoms (compatible with Hospital Anxiety and Depression Scale-Depression subscale, ≥ 8) across all studies, using all instruments, was between 29% and 30% at all three time points. The pooled change in prevalence (95% CI) from 2-3 to 6 months (four studies; n = 387) was 5% (-1% to +12%), and from 6 to 12 months (three studies; n = 412) was 1% (-6% to +7%). Risk factors included pre-ICU psychologic morbidity and presence of in-ICU psychologic distress symptoms. We did not identify any post-ICU intervention with strong evidence of improvement in depressive symptoms. CONCLUSIONS Clinically important depressive symptoms occurred in approximately one-third of ICU survivors and were persistent through 12-month follow-up. Greater research into treatment is needed for this common and persistent post-ICU morbidity.
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410
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Outcome Measurement in ICU Survivorship Research From 1970 to 2013: A Scoping Review of 425 Publications. Crit Care Med 2017; 44:1267-77. [PMID: 26992067 DOI: 10.1097/ccm.0000000000001651] [Citation(s) in RCA: 142] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To evaluate the study designs and measurement instruments used to assess physical, cognitive, mental health, and quality of life outcomes of survivors of critical illness over more than 40 years old as a first step toward developing a core outcome set of measures for future trials to improve outcomes in ICU survivors. DESIGN Scoping review. SETTING Published articles that included greater than or equal to one postdischarge measure of a physical, cognitive, mental health, or quality of life outcome in more than or equal to 20 survivors of critical illness published between 1970 and 2013. Instruments were classified using the World Health Organization's International Classification of Functioning, Disability, and Health framework. SUBJECTS ICU survivors. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We reviewed 15,464 abstracts, and identified 425 eligible articles, including 31 randomized trials (7%), 116 cross-sectional studies (27%), and 278 cohort studies (65%). Cohort studies had a median (interquartile range) sample size of 96 survivors (52-209), with 38% not fully reporting loss to follow-up. A total of 250 different measurement instruments were used in these 425 articles. Among eligible articles, 25 measured physical activity limitations (6%), 40 measured cognitive activity limitations (9%), 114 measured mental health impairment (27%), 196 measured participation restriction (46%), and 276 measured quality of life (65%). CONCLUSIONS Peer-reviewed publications reporting patient outcomes after hospital discharge for ICU survivors have grown from 3 in the 1970s to more than 300 since 2000. Although there is evidence of consolidation in the instruments used for measuring participation restriction and quality of life, the ability to compare results across studies remains impaired by the 250 different instruments used. Most articles described cohort studies of modest size with a single follow-up assessment using patient-reported measures of participation restriction and quality of life. Development of a core outcome set of valid, reliable, and feasible measures is essential to improving the outcomes of critical illness survivors.
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411
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Abstract
OBJECTIVE To assess patients' recollections of in-ICU procedural pain and its impact on post-ICU burden. DESIGN Prospective longitudinal study of patients who underwent ICU procedures. SETTING Thirty-four ICUs in France and Belgium. PATIENTS Two hundred thirty-six patients who had undergone ICU procedures. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Patients were interviewed 3-16 months after hospitalization about: 1) recall of procedural pain intensity and pain distress (on 0-10 numeric rating scale); 2) current pain; that is, having pain in the past week that was not present before hospitalization; and 3) presence of traumatic stress (Impact of Events Scale). For patients who could rate recalled procedural pain intensity (n = 56) and pain distress (n = 43), both were significantly higher than their median (interquartile range) in ICU procedural pain scores (pain intensity: 5 [4-7] vs 3 [2.5-5], p < 0.001; pain distress: 5 [2-6] vs 2 [0-6], p = 0.003, respectively.) Current pain was reported in 14% of patients. When comparing patients with and without current pain, patients with current pain recalled even greater ICU procedural pain intensity and pain distress scores than patients without current pain: pain intensity, 8 (6-8) versus 5 (3.25-7); p = 0.002 and pain distress, 7 (5-8) versus 4 (2-6); p = 0.01, respectively. Patients with current pain also had significantly higher Impact of Events Scale scores than those without current pain (8.5 [3.5-24] vs 2 [0-10]; p < 0.001). CONCLUSION Many patients remembered ICU, with far fewer able to rate procedure-associated pain. For those able to do so, recalled pain intensity and pain distress scores were significantly greater than reported in ICU. One in seven patients was having current pain, recalling even higher ICU procedural pain scores and greater traumatic stress when compared with patients without current pain. Studies are needed to assess the impact of ICU procedural pain on post-ICU pain recall, pain status over time, and the relationship between postdischarge pain status and post-ICU burden.
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412
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Patel MB, Jackson JC, Morandi A, Girard TD, Hughes CG, Thompson JL, Kiehl AL, Elstad MR, Wasserstein ML, Goodman RB, Beckham JC, Chandrasekhar R, Dittus RS, Ely EW, Pandharipande PP. Incidence and Risk Factors for Intensive Care Unit-related Post-traumatic Stress Disorder in Veterans and Civilians. Am J Respir Crit Care Med 2017; 193:1373-81. [PMID: 26735627 DOI: 10.1164/rccm.201506-1158oc] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
RATIONALE The incidence and risk factors of post-traumatic stress disorder (PTSD) related to the intensive care unit (ICU) experience have not been reported in a mixed veteran and civilian cohort. OBJECTIVES To describe the incidence and risk factors for ICU-related PTSD in veterans and civilians. METHODS This is a prospective, observational, multicenter cohort enrolling adult survivors of critical illness after respiratory failure and/or shock from three Veterans Affairs and one civilian hospital. After classifying those with/without preexisting PTSD (i.e., PTSD before hospitalization), we then assessed all subjects for ICU-related PTSD at 3 and 12 months post hospitalization. MEASUREMENTS AND MAIN RESULTS Of 255 survivors, 181 and 160 subjects were assessed for ICU-related PTSD at 3- and 12-month follow-up, respectively. A high probability of ICU-related PTSD was found in up to 10% of patients at either follow-up time point, whether assessed by PTSD Checklist Event-Specific Version (score ≥ 50) or item mapping using the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). In the multivariable regression, preexisting PTSD was independently associated with ICU-related PTSD at both 3 and 12 months (P < 0.001), as was preexisting depression (P < 0.03), but veteran status was not a consistent independent risk factor for ICU-related PTSD (3-month P = 0.01, 12-month P = 0.48). CONCLUSIONS This study found around 1 in 10 ICU survivors experienced ICU-related PTSD (i.e., PTSD anchored to their critical illness) in the year after hospitalization. Preexisting PTSD and depression were strongly associated with ICU-related PTSD.
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Affiliation(s)
- Mayur B Patel
- 1 Surgical Services, Nashville VA Medical Center, Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee.,2 Division of Trauma and Surgical Critical Care, Departments of Surgery and Neurosurgery, Section of Surgical Sciences, Vanderbilt Brain Institute, Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James C Jackson
- 3 Geriatric Research, Education, and Clinical Center, Nashville VA Medical Center, Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee.,4 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee.,5 Department of Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alessandro Morandi
- 6 Department of Rehabilitation and Aged Care Unit, Hospital Ancelle, Cremona, Italy.,7 Geriatric Research Group, Brescia, Italy
| | - Timothy D Girard
- 3 Geriatric Research, Education, and Clinical Center, Nashville VA Medical Center, Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee.,4 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher G Hughes
- 8 Anesthesia Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee.,9 Division of Critical Care, Department of Anesthesiology, Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jennifer L Thompson
- 10 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Amy L Kiehl
- 4 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark R Elstad
- 11 George E. Wahlen Department of Veterans Affairs Medical Center, VA Salt Lake City Health Care System, U.S. Department of Veterans Affairs, Salt Lake City, Utah.,12 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Mitzi L Wasserstein
- 11 George E. Wahlen Department of Veterans Affairs Medical Center, VA Salt Lake City Health Care System, U.S. Department of Veterans Affairs, Salt Lake City, Utah
| | - Richard B Goodman
- 13 Seattle Division, VA Puget Sound Health Care System, U.S. Department of Veterans Affairs, Seattle, Washington.,14 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Jean C Beckham
- 15 Veterans Affairs Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, U.S. Department of Veterans Affairs Medical Center, Durham, North Carolina.,16 Behavioral Medicine Division, Department of Psychiatry, Duke University Medical Center, Durham, North Carolina; and
| | - Rameela Chandrasekhar
- 10 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Robert S Dittus
- 3 Geriatric Research, Education, and Clinical Center, Nashville VA Medical Center, Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee.,17 Division of General Internal Medicine and Public Health and Department of Medicine, Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E Wesley Ely
- 3 Geriatric Research, Education, and Clinical Center, Nashville VA Medical Center, Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee.,4 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Pratik P Pandharipande
- 8 Anesthesia Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee.,9 Division of Critical Care, Department of Anesthesiology, Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
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Abstract
OBJECTIVES To determine whether delirium during ICU stay is associated with long-term mental health problems defined as symptoms of anxiety, depression, and posttraumatic stress disorder. DESIGN Prospective cohort study. SETTING Survey study, 1 year after discharge from a medical-surgical ICU in the Netherlands. PATIENTS One-year ICU survivors of an ICU admission lasting more than 48 hours, without a neurologic disorder or other condition that would impede delirium assessment during ICU stay. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One year after discharge, ICU survivors received a survey containing the Hospital Anxiety and Depression Scale with a subscale for symptoms of depression and a subscale for symptoms of anxiety, and the Impact of Event Scale 15 item measuring symptoms of posttraumatic stress disorder. Participants were classified as having experienced no delirium (n = 270; 48%), a single day of delirium (n = 86; 15%), or multiple days of delirium (n = 211; 37%) during ICU stay. Log-binomial regression was used to assess the association between delirium and symptoms of anxiety, depression, and posttraumatic stress disorder. The study population consisted of 567 subjects; of whom 246 subjects (43%) reported symptoms of anxiety (Hospital Anxiety and Depression Scale with a subscale for anxiety, ≥ 8), and 254 (45%) symptoms of depression (Hospital Anxiety and Depression Scale with a subscale for depression, ≥ 8). In 220 patients (39%), the Impact of Event Scale 15 item was greater than or equal to 35, indicating a high probability of posttraumatic stress disorder. There was substantial overlap between these mental health problems-63% of the subjects who scored positive for the presence of any three of the mental health problems, scored positive for all three. No association was observed between either a single day or multiple days of delirium and symptoms of anxiety, depression, or posttraumatic stress disorder. CONCLUSIONS Although symptoms of anxiety, depression, and posttraumatic stress disorder were found to be common 1 year after critical illness, the occurrence of delirium during ICU stay did not increase the risk of these long-term mental health problems.
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414
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The Untapped Potential of Patient and Family Engagement in the Organization of Critical Care. Crit Care Med 2017; 45:899-906. [PMID: 28234753 DOI: 10.1097/ccm.0000000000002282] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE There is growing interest in patient and family participation in critical care-not just as part of the bedside, but as part of educational and management organization and infrastructure. This offers tremendous opportunities for change but carries risk to patients, families, and the institution. The objective is to provide a concise definitive review of patient and family organizational participation in critical care as a high-risk population and other vulnerable groups. A pragmatic, codesigned model for critical care is offered as a suggested approach for clinicians, researchers, and policy-makers. DATA SOURCES To inform this review, a systematic search of Ovid Medline, PubMed, and Embase was undertaken in April 2016 using the MeSH terms: patient participation and critical care. A second search was undertaken in PubMed using the terms: patient participation and organizational models to search for other examples of engagement in vulnerable populations. We explicitly did not seek to include discussions of bedside patient-family engagement or shared decision-making. STUDY SELECTION Two reviewers screened citations independently. Included studies either actively partnered with patients and families or described a model of engagement in critical care and other vulnerable populations. DATA EXTRACTION Data or description of how patient and family engagement occurred and/or description of model were extracted into a standardized form. DATA SYNTHESIS There was limited evidence of patient and family engagement in critical care although key recommendations can be drawn from included studies. Patient and family engagement is occurring in other vulnerable populations although there are few described models and none which address issues of risk. CONCLUSIONS A model of patient and family engagement in critical care does not exist, and we propose a pragmatic, codesigned model that takes into account issues of psychologic safety in this population. Significant opportunity exists to document processes of engagement that reflect a changing paradigm of healthcare delivery.
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415
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Sher Y, Zimbrean P. Psychiatric Aspects of Organ Transplantation in Critical Care: An Update. Crit Care Clin 2017; 33:659-679. [PMID: 28601140 DOI: 10.1016/j.ccc.2017.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Transplant patients face challenging medical journeys, with many detours to the intensive care unit. Before and after transplantation, they have significant psychological and cognitive comorbidities, which decrease their quality of life and potentially compromise their medical outcomes. Critical care staff are essential in these journeys. Being cognizant of relevant psychosocial and mental health aspects of transplant patients' experiences can help critical care personnel take comprehensive care of these patients. This knowledge can empower them to understand their patients' psychological journeys, recognize patients' mental health needs, provide initial interventions, and recognize need for expert consultations.
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Affiliation(s)
- Yelizaveta Sher
- Department of Psychiatry and Behavioral Sciences, Stanford University Medical Center, 401 Quarry Road, Suite 2320, Stanford, CA, 94305, USA.
| | - Paula Zimbrean
- Departments of Psychiatry and Surgery (Transplant), Yale New Haven Hospital, 20 York Street, Fitkin 611, New Haven, CT 06511, USA
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416
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Affiliation(s)
- Judy E Davidson
- Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, Mail Code 8929, 200 W Arbor Drive, San Diego CA 92103 Maurene A. Harvey is an Educational Consultant, Lake Tahoe, Nevada
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Dreyfus L, Javouhey E, Denis A, Touzet S, Bordet F. Implementation and evaluation of a paediatric nurse-driven sedation protocol in a paediatric intensive care unit. Ann Intensive Care 2017; 7:36. [PMID: 28341980 PMCID: PMC5366991 DOI: 10.1186/s13613-017-0256-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 03/08/2017] [Indexed: 12/02/2022] Open
Abstract
Background Optimal sedation and analgesia is a challenge in paediatric intensive care units (PICU) because of difficulties in scoring systems and specific metabolism inducing tolerance and withdrawal. Excessive sedation is associated with prolonged mechanical ventilation and hospitalisation. Adult and paediatric data suggest that goal-directed sedation algorithms reduce the duration of mechanical ventilation. We implemented a nurse-driven sedation protocol in a PICU and evaluated its impact. Methods We conducted a before and after protocol implementation study in a population of children aged 0–18 years who required mechanical ventilation for at least 24 h between January 2013 and March 2015. After the protocol implementation in January 2014, nurses managed analgesia and sedation following an algorithm that included the COMFORT behaviour scale (COMFORT-B). Duration of mechanical ventilation was the primary outcome; secondary outcomes were total doses and duration of medications, PICU length of stay, incidence of ventilator-associated pneumonia, and occurrence of withdrawal symptoms. Pre–post analysis followed with segmented regression analysis of interrupted time series was used to assess the effect of protocol. Results A total of 200 children were analysed, including 107 before implementation and 93 children after implementation of the protocol. After implementation of the protocol, the total number of COMFORT-B scores per day of mechanical ventilation significantly increased from 3.9 ± 2.5 times during the pre-implementation period to 6.6 ± 3.5 times during the post-implementation period (p < 10−3). Mean duration of mechanical ventilation tended to be lower in the post-implementation period (8.3 ± 7.3 vs 6.6 ± 5.6 days, p = 0.094), but changes in either the trend per trimester from pre-implementation to post-implementation (p = 0.933) or the immediate change after implementation (p = 0.923) were not significant with segmented regression analysis. No significant change between pre- and post-implementation was shown for total dose of sedatives, withdrawal symptoms, agitation episodes, or unplanned endotracheal extubations. Conclusions These results were promising and suggested that implementation of a nurse-driven sedation protocol in a PICU was feasible. Evaluation of sedation and analgesia was better after the protocol implementation; duration of mechanical ventilation and occurrence of withdrawal symptoms tended to be reduced. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0256-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lélia Dreyfus
- Service de réanimation pédiatrique, Hospices Civils de Lyon - Hôpital Femme Mère Enfant, 59, Boulevard Pinel, 69500, Bron, France.
| | - Etienne Javouhey
- Service de réanimation pédiatrique, Hospices Civils de Lyon - Hôpital Femme Mère Enfant, 59, Boulevard Pinel, 69500, Bron, France.,Université Claude-Bernard Lyon 1, 69008, Lyon, France
| | - Angélique Denis
- Pôle information médicale évaluation recherche, Hospices Civils de Lyon, 162 avenue Lacassagne Bâtiment A, 69003, Lyon, France
| | - Sandrine Touzet
- Pôle information médicale évaluation recherche, Hospices Civils de Lyon, 162 avenue Lacassagne Bâtiment A, 69003, Lyon, France.,HESPER EA 7425, Université Claude Bernard Lyon 1, 69008, Lyon, France
| | - Fabienne Bordet
- Service de réanimation pédiatrique, Hospices Civils de Lyon - Hôpital Femme Mère Enfant, 59, Boulevard Pinel, 69500, Bron, France
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418
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Haugdahl HS, Dahlberg H, Klepstad P, Storli SL. The breath of life. Patients' experiences of breathing during and after mechanical ventilation. Intensive Crit Care Nurs 2017; 40:85-93. [PMID: 28341400 DOI: 10.1016/j.iccn.2017.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 01/11/2017] [Accepted: 01/13/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Breathlessness is a prevalent and distressing symptom in intensive care, underestimated by nurses and physicians. Therefore, to develop a more comprehensive understanding of this problem, the study had two aims: to compare patients' self-reported scores of breathlessness obtained during mechanical ventilation (MV) with experiences of breathlessness later recalled by patients and: to explore the lived experience of breathing during and after MV. METHOD A qualitatively driven sequential mixed method design combining prospective observational breathlessness data at the end of a spontaneous breathing trial (SBT) and follow up data from 11 post-discharge interviews. FINDINGS Four out of six patients who reported breathlessness at the end of an SBT did not remember being breathless in retrospect. Experiences of breathing intertwined with the whole illness experience and were described in four themes: existential threat; the tough time; an amorphous and boundless body and getting through. CONCLUSION Breathing was not always a clearly separate experience, but intertwined with the whole illness experience. This may explain the poor correspondence between patients' and clinicians assessments of breathlessness. The results suggest patients' own reports of breathing should form part of nursing interventions and follow-up to support patients' quest for meaning.
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Affiliation(s)
- Hege S Haugdahl
- UiT The Arctic University of Norway, Tromsø, Norway; Nord University, Levanger, Norway; Nord-Trøndelag Hospital Trust, Levanger, Norway.
| | | | - Pål Klepstad
- St. Olav University Hospital, Trondheim, Norway; Norwegian University of Science and Technology, Trondheim, Norway
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419
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Kean S, Salisbury LG, Rattray J, Walsh TS, Huby G, Ramsay P. ‘Intensive care unit survivorship’ - a constructivist grounded theory of surviving critical illness. J Clin Nurs 2017; 26:3111-3124. [DOI: 10.1111/jocn.13659] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Susanne Kean
- School of Health in Social Science; Nursing Studies; The University of Edinburgh; Edinburgh UK
| | - Lisa G Salisbury
- School of Health in Social Science; Nursing Studies; The University of Edinburgh; Edinburgh UK
| | - Janice Rattray
- School of Nursing & Midwifery; University of Dundee; Dundee UK
| | - Timothy S Walsh
- School of Clinical Science; Queens Medical Research Institute; The University of Edinburgh; Edinburgh UK
| | - Guro Huby
- Faculty of Health and Social Studies; Østfold University College; Halden Norway
| | - Pamela Ramsay
- School of Nursing; Midwifery & Social Care; Edinburgh Napier University; Edinburgh UK
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420
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[Posttraumatic stress disorder after intensive care : Prevalence, risk factors, and treatment]. Med Klin Intensivmed Notfmed 2017; 114:9-14. [PMID: 28258361 DOI: 10.1007/s00063-017-0266-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/28/2016] [Accepted: 01/27/2017] [Indexed: 01/29/2023]
Abstract
Posttraumatic stress disorder (PTSD) is a common consequence of intensive care which might affect not only the patients but also their relatives. About one fifth of these patients develop clinically important PTSD in the first year after intensive care. Comorbid psychopathology, received benzodiazepines, and memories of the frightening, distressing ICU experiences are common risk factors for the development of PTSD symptoms. There are only a few specific approaches for the treatment of PTSD after intensive care. The efficacy of intensive care diaries has only been examined in a few studies, but could not yet be confirmed clearly. Internet-based writing therapy represents a further treatment option where the partner also becomes involved in the treatment.
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421
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Gawlytta R, Niemeyer H, Böttche M, Scherag A, Knaevelsrud C, Rosendahl J. Internet-based cognitive-behavioural writing therapy for reducing post-traumatic stress after intensive care for sepsis in patients and their spouses (REPAIR): study protocol for a randomised-controlled trial. BMJ Open 2017; 7:e014363. [PMID: 28232467 PMCID: PMC5337733 DOI: 10.1136/bmjopen-2016-014363] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION As a consequence of sepsis and intensive care, considerable proportions of patients but also of their spouses develop a post-traumatic stress disorder (PTSD). However, only a very small number receive psychotherapeutic treatment. Internet-based cognitive-behavioural writing therapy (IB-CBWT) has proven to be an effective treatment option for PTSD. It seems to fit the specific needs of this cohort and to overcome treatment barriers. Aim of the REPAIR trial is to examine the efficacy, safety and applicability of IB-CBWT for PTSD in patients and their spouses after intensive care for sepsis. METHODS AND ANALYSIS Participants will be assigned randomly either to a treatment or a wait-list (WL) control group. The treatment group receives IB-CBWT for PTSD, actively involving the partners of the participants. IB-CBWT will be guided by a therapist and comprises two written assignments per week over a 5 week period. After completing the assignments, the participants obtain individual responses from the therapist. Participants of the WL control group will receive treatment after a waiting period of 5 weeks. The primary outcome is PTSD symptom severity in self-rated PTSD Checklist for Diagnostic and Statistical Manual Fifth Edition at the end of treatment and waiting time, respectively. Secondary outcomes are remission of PTSD, depression, anxiety, and somatisation measured by the Brief Symptom Inventory-18, marital satisfaction measured by the Relationship Assessment Scale, health-related quality of life measured by the EQ-5D-5L, and the feasibility of IB-CBWT for this cohort (ie, dropout rate). Statistical analysis will be performed according to the intent-to-treat principle. ETHICS AND DISSEMINATION The study is conducted according to the principles of Good Clinical Practice and has been approved by the ethics committee of the Friedrich-Schiller University Jena, Germany. Results will be disseminated at scientific conferences, published in peer-reviewed journals, and provided to consumers of healthcare. TRIAL REGISTRATION NUMBER Pre-results, DRKS00010676.
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Affiliation(s)
- Romina Gawlytta
- Institute of Psychosocial Medicine and Psychotherapy, Jena University Hospital, Jena, Germany
- Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Helen Niemeyer
- Department of Clinical Psychological Intervention, Freie Universität Berlin, Berlin, Germany
| | - Maria Böttche
- Department of Clinical Psychological Intervention, Freie Universität Berlin, Berlin, Germany
- Berlin Center for Torture Victims, Zentrum ÜBERLEBEN, Berlin, Germany
| | - André Scherag
- Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Christine Knaevelsrud
- Department of Clinical Psychological Intervention, Freie Universität Berlin, Berlin, Germany
| | - Jenny Rosendahl
- Institute of Psychosocial Medicine and Psychotherapy, Jena University Hospital, Jena, Germany
- Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
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422
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Nedergaard HK, Jensen HI, Toft P. Interventions to reduce cognitive impairments following critical illness: a topical systematic review. Acta Anaesthesiol Scand 2017; 61:135-148. [PMID: 27878815 DOI: 10.1111/aas.12832] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/19/2016] [Accepted: 10/24/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Critical illness is associated with cognitive impairments. Effective treatment or prevention has not been established. The aim of this review was to create a systematic summary of the current evidence concerning clinical interventions during intensive care admission to reduce cognitive impairments after discharge. METHODS Medline, Embase, Cochrane Central, PsycInfo and Cinahl were searched. Inclusion criteria were studies assessing the effect of interventions during intensive care admission on cognitive function in adult patients. Studies were excluded if they were reviews or reported solely on survivors of cardiac arrest, stroke or traumatic brain injury. RESULTS Of 4877 records were identified. Seven studies fulfilled the eligibility criteria. The interventions described covered strategies for enteral nutrition, fluids, sedation, weaning, mobilization, cognitive activities, statins and sleep quality improvement. Data were synthesized to provide an overview of interventions, quality, follow-up assessments and neuropsychological outcomes. CONCLUSION None of the interventions had significant positive effects on cognitive impairments following critical illness. Quality was negatively affected by study limitations, imprecision and indirectness in evidence. Clinical research on cognition is feasible, but large, well designed trials with a specific aim at reducing cognitive impairments are needed.
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Affiliation(s)
- H. K. Nedergaard
- Department of Anesthesiology and Intensive Care; Lillebaelt Hospital; Kolding Denmark
- University of Southern Denmark; Odense Denmark
| | - H. I. Jensen
- Department of Anesthesiology and Intensive Care; Lillebaelt Hospital; Kolding Denmark
- University of Southern Denmark; Odense Denmark
| | - P. Toft
- University of Southern Denmark; Odense Denmark
- Department of Anesthesiology and Intensive Care; Odense University Hospital; Odense Denmark
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423
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Ohtake PJ, Coffey Scott J, Hinman RS, Lee AC, Smith JM. Impairments, activity limitations and participation restrictions experienced in the first year following a critical illness: protocol for a systematic review. BMJ Open 2017; 7:e013847. [PMID: 28119388 PMCID: PMC5278234 DOI: 10.1136/bmjopen-2016-013847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Critical illness requiring intensive care unit (ICU) management is a life-altering event with ∼25% of ICU survivors experiencing persistent reductions in physical functioning, impairments in mental health, cognitive dysfunction and decreased quality of life. This constellation of problems is known as 'postintensive care syndrome' (PICS) and may persist for months and/or years. The purpose of this systematic review is to identify the scope and magnitude of physical problems associated with PICS during the first year after discharge from ICU, using the International Classification of Functioning, Disability and Health framework to elucidate the impairments of body functions and structures, activity limitations and participation restrictions. METHODS AND ANALYSIS Medline (Ovid), Cochrane Database of Systematic Reviews (Ovid), Cochrane Central Register of Controlled Trials (Ovid), PubMed, CINAHL (EBSCO), Web of Science and EMBASE will be systematically searched for observational studies reporting the physical impairments of body functions and structures, activity limitations and participation restrictions associated with PICS. Two reviewers will assess the articles for eligibility according to prespecified selection criteria, after which an independent reviewer will perform data extraction which will be validated by a second independent reviewer. Quality appraisal will be performed by two independent reviewers. Outcomes of the included studies will be summarised in tables and in narrative format and meta-analyses will be conducted where appropriate. ETHICS AND DISSEMINATION Formal ethical approval is not required as no primary data is collected. This systematic review will identify the scope and magnitude of physical problems associated with PICS during the first year after discharge from ICU and will be disseminated through a peer-reviewed publication and at conference meetings, to inform practice and future research on the physical problems associated with PICS. TRIAL REGISTRATION NUMBER CRD42015023520.
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Affiliation(s)
- Patricia J Ohtake
- Department of Rehabilitation Science, University at Buffalo, Buffalo, New York, USA
| | | | - Rana S Hinman
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Alan Chong Lee
- Department of Physical Therapy, Mount Saint Mary's University, Los Angeles, California, USA
| | - James M Smith
- Physical Therapy Department, Utica College, Utica, New York, USA
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424
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Koenen KC, Sumner JA, Gilsanz P, Glymour MM, Ratanatharathorn A, Rimm EB, Roberts AL, Winning A, Kubzansky LD. Post-traumatic stress disorder and cardiometabolic disease: improving causal inference to inform practice. Psychol Med 2017; 47:209-225. [PMID: 27697083 PMCID: PMC5214599 DOI: 10.1017/s0033291716002294] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Post-traumatic stress disorder (PTSD) has been declared 'a life sentence' based on evidence that the disorder leads to a host of physical health problems. Some of the strongest empirical research - in terms of methodology and findings - has shown that PTSD predicts higher risk of cardiometabolic diseases, specifically cardiovascular disease (CVD) and type 2 diabetes (T2D). Despite mounting evidence, PTSD is not currently acknowledged as a risk factor by cardiovascular or endocrinological medicine. This view is unlikely to change absent compelling evidence that PTSD causally contributes to cardiometabolic disease. This review suggests that with developments in methods for epidemiological research and the rapidly expanding knowledge of the behavioral and biological effects of PTSD the field is poised to provide more definitive answers to questions of causality. First, we discuss methods to improve causal inference using the observational data most often used in studies of PTSD and health, with particular reference to issues of temporality and confounding. Second, we consider recent work linking PTSD with specific behaviors and biological processes, and evaluate whether these may plausibly serve as mechanisms by which PTSD leads to cardiometabolic disease. Third, we evaluate how looking more comprehensively into the PTSD phenotype provides insight into whether specific aspects of PTSD phenomenology are particularly relevant to cardiometabolic disease. Finally, we discuss new areas of research that are feasible and could enhance understanding of the PTSD-cardiometabolic relationship, such as testing whether treatment of PTSD can halt or even reverse the cardiometabolic risk factors causally related to CVD and T2D.
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Affiliation(s)
- K C Koenen
- Department of Epidemiology,Harvard T.H. Chan School of Public Health,Boston, MA,USA
| | - J A Sumner
- Department of Epidemiology,Harvard T.H. Chan School of Public Health,Boston, MA,USA
| | - P Gilsanz
- Department of Social and Behavioral Sciences,Harvard T.H. Chan School of Public Health,Boston, MA,USA
| | - M M Glymour
- Department of Social and Behavioral Sciences,Harvard T.H. Chan School of Public Health,Boston, MA,USA
| | - A Ratanatharathorn
- Department of Epidemiology,Harvard T.H. Chan School of Public Health,Boston, MA,USA
| | - E B Rimm
- Channing Division of Network Medicine,Brigham and Women's Hospital,Harvard Medical School and Departments of Epidemiology and Nutrition,Harvard T.H. Chan School of Public Health,Boston, MA,USA
| | - A L Roberts
- Department of Social and Behavioral Sciences,Harvard T.H. Chan School of Public Health,Boston, MA,USA
| | - A Winning
- Department of Social and Behavioral Sciences,Harvard T.H. Chan School of Public Health,Boston, MA,USA
| | - L D Kubzansky
- Department of Social and Behavioral Sciences,Harvard T.H. Chan School of Public Health,Boston, MA,USA
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425
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Takashima N, Murata H, Nishikaichi Y, Yamaguchi Y, Sakaki K, Takinami M. Stressful experiences in the ICU of patients put on mechanical ventilators for 12 hours or more. ACTA ACUST UNITED AC 2017. [DOI: 10.3918/jsicm.24_399] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | | | | | - Yoko Yamaguchi
- Department of Intensive Care Unit, Jikei University Hospital
| | - Kohsuke Sakaki
- Department of Intensive Care Unit, Jikei University Hospital
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426
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Abstract
Delirium is common in critically ill patients and associated with increased length of stay in the intensive care unit (ICU) and long-term cognitive impairment. The pathophysiology of delirium has been explained by neuroinflammation, an aberrant stress response, neurotransmitter imbalances, and neuronal network alterations. Delirium develops mostly in vulnerable patients (e.g., elderly and cognitively impaired) in the throes of a critical illness. Delirium is by definition due to an underlying condition and can be identified at ICU admission using prediction models. Treatment of delirium can be improved with frequent monitoring, as early detection and subsequent treatment of the underlying condition can improve outcome. Cautious use or avoidance of benzodiazepines may reduce the likelihood of developing delirium. Nonpharmacologic strategies with early mobilization, reducing causes for sleep deprivation, and reorientation measures may be effective in the prevention of delirium. Antipsychotics are effective in treating hallucinations and agitation, but do not reduce the duration of delirium. Combined pain, agitation, and delirium protocols seem to improve the outcome of critically ill patients and may reduce delirium incidence.
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Affiliation(s)
- A J C Slooter
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - R R Van De Leur
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I J Zaal
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
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427
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[Depressive, anxiety and posttraumatic stress disorders as long-term sequelae of intensive care treatment]. DER NERVENARZT 2016; 87:253-63. [PMID: 26908007 DOI: 10.1007/s00115-016-0070-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Modern intensive care medicine has led to increased survival rates even after severe life-threatening medical conditions. In self-critical and multidimensional outcome research, however, it must be considered that beyond survival rates treatment on intensive care units (ICU) can also be associated with high long-term rates of depressive, anxiety and posttraumatic stress disorders. Significant correlations with increased somatic morbidity and mortality, persisting cognitive impairments and significant deficits in health-related quality of life must also be taken into consideration. Empirical analysis of the risk factors reveals that a history of premorbid depression, sociodemographic and socioeconomic variables, age, female sex, personality traits, the underlying pathophysiological condition requiring ICU treatment, mode of sedation and analgesia, life support measures, such as mechanical ventilation, manifold traumatic experiences and memories during the stay in the ICU are all of particular pathogenetic importance. In order to reduce principally modifiable risk factors several strategies are illustrated, including well-reflected intensive care sedation and analgesia, special prophylactic medication regarding the major risk of traumatic memories and posttraumatic stress disorder (PTSD), psychological and psychotherapeutic interventions in states of increased acute stress symptoms and aids for personal memories and reorientation.
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428
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Abstract
Complications involving the central and peripheral nervous system are frequently encountered in critically ill patients. All components of the neuraxis can be involved including the brain, spinal cord, peripheral nerves, neuromuscular junction, and muscles. Neurologic complications adversely impact outcome and length of stay. These complications can be related to underlying critical illness, pre-existing comorbid conditions, and commonly used and life-saving procedures and medications. Familiarity with the myriad neurologic complications that occur in the intensive care unit can facilitate their timely recognition and treatment. Additionally, awareness of treatment-related neurologic complications may inform decision-making, mitigate risk, and improve outcomes.
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Affiliation(s)
- Clio Rubinos
- Department of Neurology, Loyola University Chicago-Stritch School of Medicine, Maywood, IL, 60153, USA
| | - Sean Ruland
- Department of Neurology, Loyola University Chicago-Stritch School of Medicine, Maywood, IL, 60153, USA.
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429
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Evans DJW, Lewis SR, Alderson P, Smith AF. Information or education interventions for adult intensive care unit (ICU) patients and their carers. Hippokratia 2016. [DOI: 10.1002/14651858.cd012471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- David JW Evans
- Lancaster University; Lancaster Health Hub; Lancaster UK LA1 4YG
| | - Sharon R Lewis
- Royal Lancaster Infirmary; Patient Safety Research Department; Pointer Court 1, Ashton Road Lancaster UK LA1 4RP
| | - Phil Alderson
- National Institute for Health and Care Excellence; Level 1A, City Tower, Piccadilly Plaza Manchester UK M1 4BD
| | - Andrew F Smith
- Royal Lancaster Infirmary; Department of Anaesthesia; Ashton Road Lancaster Lancashire UK LA1 4RP
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430
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Tang L, Pan L, Yuan L, Zha L. Prevalence and related factors of post-traumatic stress disorder among medical staff members exposed to H7N9 patients. Int J Nurs Sci 2016; 4:63-67. [PMID: 31406720 PMCID: PMC6626070 DOI: 10.1016/j.ijnss.2016.12.002] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 12/07/2016] [Indexed: 12/17/2022] Open
Abstract
Objective This study aimed to evaluate the prevalence and related factors of post-traumatic stress disorder (PTSD) symptoms among doctors and nurses who were exposed to H7N9 patients during the H7N9 influenza epidemic. To provide scientific basis for promoting the physical and psychological health of these staff members. Method The 102 medical staff workers who were exposed to H7N9 patients were recruited through convenient sampling between January 2015 and May 2016. We used a self-reported questionnaire, the PTSD Checklist-Civilian Version (PCL-C), to evaluate the PTSD symptoms among doctors and nurses from an intensive care unit (n = 61), a respiratory department (n = 20), and an emergency department (n = 21). We then analyzed the related factors. Results Around 20.59% of the tested doctors and nurses showed PTSD symptoms. The sample had a mean PCL-C score of 30.00 ± 9.95. The differences in the scores of doctors and nurses with different genders, ages, professional titles, contact frequencies, trainings, and experiences were statistically significant (P < 0.05, P < 0.01). Moreover, t-tests and one-way analysis of variance showed that nurses received higher scores than doctors, female participants received higher scores than male participants, and the participants with low professional title and high contact frequency, aged between 20 years and 30 years, with less than five years of work experience, having not received related training and with no related experience obtained higher PCL-C scores than the others (P < 0.05, P < 0.01). Conclusion The PTSD level of doctors and nurses after their exposure to H7N9 patients was high, which warrant further research. Health and medical institutions should pay attention to the physical and psychological health of these staff members.
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Affiliation(s)
- Liling Tang
- Nursing Department, The First Affiliated Hospital of Wannan Medical College, Wuhu, 241000, An Hui Province, China
| | - Lingling Pan
- Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, 241000, An Hui Province, China
| | - Liping Yuan
- Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, 241000, An Hui Province, China
| | - Lei Zha
- Intensive Care Unit, The Second People's Hospital of Wuhu, Wuhu, 241000, An Hui Province, China
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431
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Ganzel BL. Trauma-Informed Hospice and Palliative Care. THE GERONTOLOGIST 2016; 58:409-419. [DOI: 10.1093/geront/gnw146] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 07/07/2016] [Indexed: 12/12/2022] Open
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432
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Hashem MD, Nallagangula A, Nalamalapu S, Nunna K, Nausran U, Robinson KA, Dinglas VD, Needham DM, Eakin MN. Patient outcomes after critical illness: a systematic review of qualitative studies following hospital discharge. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:345. [PMID: 27782830 PMCID: PMC5080744 DOI: 10.1186/s13054-016-1516-x] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 09/28/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND There is growing interest in patient outcomes following critical illness, with an increasing number and different types of studies conducted, and a need for synthesis of existing findings to help inform the field. For this purpose we conducted a systematic review of qualitative studies evaluating patient outcomes after hospital discharge for survivors of critical illness. METHODS We searched the PubMed, EMBASE, CINAHL, PsycINFO, and CENTRAL databases from inception to June 2015. Studies were eligible for inclusion if the study population was >50 % adults discharged from the ICU, with qualitative evaluation of patient outcomes. Studies were excluded if they focused on specific ICU patient populations or specialty ICUs. Citations were screened in duplicate, and two reviewers extracted data sequentially for each eligible article. Themes related to patient outcome domains were coded and categorized based on the main domains of the Patient Reported Outcomes Measurement Information System (PROMIS) framework. RESULTS A total of 2735 citations were screened, and 22 full-text articles were eligible, with year of publication ranging from 1995 to 2015. All of the qualitative themes were extracted from eligible studies and then categorized using PROMIS descriptors: satisfaction with life (16 studies), including positive outlook, acceptance, gratitude, independence, boredom, loneliness, and wishing they had not lived; mental health (15 articles), including symptoms of post-traumatic stress disorder, anxiety, depression, and irritability/anger; physical health (14 articles), including mobility, activities of daily living, fatigue, appetite, sensory changes, muscle weakness, and sleep disturbances; social health (seven articles), including changes in friends/family relationships; and ability to participate in social roles and activities (six articles), including hobbies and disability. CONCLUSION ICU survivors may experience positive emotions and life satisfaction; however, a wide range of mental, physical, social, and functional sequelae occur after hospital discharge. These findings are important for understanding patient-centered outcomes in critical care and providing focus for future interventional studies aimed at improving outcomes of importance to ICU survivors.
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Affiliation(s)
- Mohamed D Hashem
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA.,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Aparna Nallagangula
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA.,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Swaroopa Nalamalapu
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA.,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Krishidhar Nunna
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA.,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Utkarsh Nausran
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA
| | - Karen A Robinson
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Victor D Dinglas
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA.,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA.,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.,Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Michelle N Eakin
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD, USA. .,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
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433
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Karnatovskaia LV, Johnson MM, Dockter TJ, Gajic O. Perspectives of physicians and nurses on identifying and treating psychological distress of the critically ill. J Crit Care 2016; 37:106-111. [PMID: 27676170 DOI: 10.1016/j.jcrc.2016.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/22/2016] [Accepted: 09/09/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE Survivors of critical illness are frequently unable to return to their premorbid level of psychocognitive functioning following discharge. Therefore, we aimed to evaluate the burden of psychological trauma experienced by patients in the intensive care unit (ICU) as perceived by clinicians to assess factors that can impede its recognition and treatment in the ICU. MATERIALS AND METHODS Two distinct role-specific Web-based surveys were administered to critical care physicians and nurses in medical and surgical ICUs of 2 academic medical centers. Responses were analyzed in the domains of psychological trauma, exacerbating/mitigating factors, and provider-patient communication. RESULTS A survey was completed by 43 physicians and 55 nurses with a response rate of 62% and 37%, respectively. Among physicians, 65% consistently consider the psychological state of the patient in decision making; 77% think it is important to introduce a system to document psychological state of ICU patients; 56% would like to have more time to communicate with patients; 77% consistently spend extra time at bedside besides rounds and often hold patient's hand/reassure them. Notably, for the question about the average level of psychological stress experienced by a patient in the ICU (with 0=no stress and 100=worst stress imaginable) during initial treatment stage and by the end of the ICU stay, median assessment by both physicians and nurses was 80 for the initial stress level and 68 for the stress level by the end of the ICU stay. Among nurses, 69% always try to minimize noise and 73% actively promote patient's rest. Physicians and nurses provided multiple specific suggestions for improving ICU environment and communication. CONCLUSIONS Both physicians and nurses acknowledge that they perceive that critically ill patients experience a high level of psychological stress that persists throughout their period of illness. Improved understanding of this phenomenon is needed to design effective therapeutic interventions. Although the lack of time is identified as significant barrier to ameliorating patient's psychological stress, the majority of clinicians indicate that they attempt to provide interventions to achieve this goal.
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Affiliation(s)
- Lioudmila V Karnatovskaia
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
| | - Margaret M Johnson
- Division of Pulmonary and Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Travis J Dockter
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905
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434
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Pfoh ER, Chan KS, Dinglas VD, Cuthbertson BH, Elliott D, Porter R, Bienvenu OJ, Hopkins RO, Needham DM. The SF-36 Offers a Strong Measure of Mental Health Symptoms in Survivors of Acute Respiratory Failure. A Tri-National Analysis. Ann Am Thorac Soc 2016; 13:1343-50. [PMID: 27111262 PMCID: PMC5021072 DOI: 10.1513/annalsats.201510-705oc] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 02/16/2016] [Indexed: 01/22/2023] Open
Abstract
RATIONALE Survivors of acute respiratory failure commonly experience long-term psychological sequelae and impaired quality of life. For researchers interested in general mental health, using multiple condition-specific instruments may be unnecessary and inefficient when using the Medical Outcomes Study Short Form (SF)-36, a recommended outcome measure, may suffice. However, relationships between the SF-36 scores and commonly used measures of psychological symptoms in acute survivors of respiratory failure are unknown. OBJECTIVES Our objective is to examine the relationship of the SF-36 mental health domain (MH) and mental health component summary (MCS) scores with symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD) evaluated using validated psychological instruments. METHODS We conducted a cross-sectional analysis of 1,229 participants at 6- and 12-month follow-up assessment using data from five studies from the United States, the United Kingdom, and Australia. MEASUREMENTS AND MAIN RESULTS Symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS), Depression Anxiety Stress Scales, the Davidson Trauma Scale, Impact of Event Scale (IES), and IES-Revised (IES-R). At 6-month assessment there were moderate to strong correlations of the SF-36 MH scores with HADS depression and anxiety symptoms (r = -0.74 and -0.79) and with IES-R PTSD symptoms (r = -0.60) in the pooled analyses. Using the normalized population mean of 50 on the SF-36 MH domain score as a cut-off, positive predictive values were 16 and 55% for substantial depression; 20 and 68% for substantial anxiety (Depression Anxiety Stress Scales and HADS, respectively); and 40, 44, and 67% for substantial PTSD symptoms (IES-R, IES, and Davidson Trauma Scale, respectively). Negative predictive values were high. The area under the receiver operating characteristics curve of the SF-36 MH score was high for depression, anxiety, and PTSD symptoms (0.88, 0.91, and 0.84, respectively). All results were consistent for the MCS, across the individual studies, and for the 12-month assessment. CONCLUSIONS For researchers interested in general mental health status, the SF-36 MH or MCS offers a strong measure of psychological symptoms prevalent among survivors of acute respiratory failure. For researchers interested in specific conditions, validated psychological instruments should be considered.
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Affiliation(s)
| | - Kitty S. Chan
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Victor D. Dinglas
- Outcomes after Critical Illness and Surgery Group
- Division of Pulmonary and Critical Care Medicine
| | - Brian H. Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Doug Elliott
- Faculty of Health, University of Technology, Sydney, Australia
| | - Richard Porter
- Adult Intensive Care Unit, Glenfield Hospital, Leicester, United Kingdom
| | | | - Ramona O. Hopkins
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah
- Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah; and
- Center for Humanizing Critical Care, Intermountain Health Care, Murray, Utah
| | - Dale M. Needham
- Outcomes after Critical Illness and Surgery Group
- Division of Pulmonary and Critical Care Medicine
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland
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435
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Walsh TS, Kydonaki K, Antonelli J, Stephen J, Lee RJ, Everingham K, Hanley J, Phillips EC, Uutela K, Peltola P, Cole S, Quasim T, Ruddy J, McDougall M, Davidson A, Rutherford J, Richards J, Weir CJ. Staff education, regular sedation and analgesia quality feedback, and a sedation monitoring technology for improving sedation and analgesia quality for critically ill, mechanically ventilated patients: a cluster randomised trial. THE LANCET RESPIRATORY MEDICINE 2016; 4:807-817. [PMID: 27473760 DOI: 10.1016/s2213-2600(16)30178-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 06/10/2016] [Accepted: 06/16/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Optimal sedation of patients in intensive care units (ICUs) requires the avoidance of pain, agitation, and unnecessary deep sedation, but these outcomes are challenging to achieve. Excessive sedation can prolong ICU stay, whereas light sedation can increase pain and frightening memories, which are commonly recalled by ICU survivors. We aimed to assess the effectiveness of three interventions to improve sedation and analgesia quality: an online education programme; regular feedback of sedation-analgesia quality data; and use of a novel sedation-monitoring technology (the Responsiveness Index [RI]). METHODS We did a cluster randomised trial in eight ICUs, which were randomly allocated to receive education alone (two ICUs), education plus sedation-analgesia quality feedback (two ICUs), education plus RI monitoring technology (two ICUs), or all three interventions (two ICUs). Randomisation was done with computer-generated random permuted blocks, stratified according to recruitment start date. A 45 week baseline period was followed by a 45 week intervention period, separated by an 8 week implementation period in which the interventions were introduced. ICU and research staff were not masked to study group assignment during the intervention period. All mechanically ventilated patients were potentially eligible. We assessed patients' sedation-analgesia quality for each 12 h period of nursing care, and sedation-related adverse events daily. Our primary outcome was the proportion of care periods with optimal sedation-analgesia, defined as being free from excessive sedation, agitation, poor limb relaxation, and poor ventilator synchronisation. Analysis used multilevel generalised linear mixed modelling to explore intervention effects in a single model taking clustering and patient-level factors into account. A concurrent mixed-methods process evaluation was undertaken to help understand the trial findings. The trial is registered with ClinicalTrials.gov, number NCT01634451. FINDINGS Between June 1, 2012, and Dec 31, 2014, we included 881 patients (9187 care periods) during the baseline period and 591 patients (6947 care periods) during the intervention period. During the baseline period, optimal sedation-analgesia was present for 5150 (56%) care periods. We found a significant improvement in optimal sedation-analgesia with RI monitoring (odds ratio [OR] 1·44 [95% CI 1·07-1·95]; p=0·017), which was mainly due to increased periods free from excessive sedation (OR 1·59 [1·09-2·31]) and poor ventilator synchronisation (OR 1·55 [1·05-2·30]). However, more patients experienced sedation-related adverse events (OR 1·91 [1·02-3·58]). We found no improvement in overall optimal sedation-analgesia with education (OR 1·13 [95% CI 0·86-1·48]), but fewer patients experienced sedation-related adverse events (OR 0·56 [0·32-0·99]). The sedation-analgesia quality data feedback did not improve quality (OR 0·74 [95% CI 0·54-1·00]) or sedation-related adverse events (OR 1·15 [0·61-2·15]). The process evaluation suggested many clinicians found the RI monitoring useful, but it was often not used for decision making as intended. Education was valued and considered useful by staff. By contrast, sedation-analgesia quality feedback was poorly understood and thought to lack relevance to bedside nursing practice. INTERPRETATION Combination of RI monitoring and online education has the potential to improve sedation-analgesia quality and patient safety in mechanically ventilated ICU patients. The RI monitoring seemed to improve sedation-analgesia quality, but inconsistent adoption by bedside nurses limited its impact. The online education programme resulted in a clinically relevant improvement in patient safety and was valued by nurses, but any changes to behaviours did not seem to alter other measures of sedation-analgesia quality. Providing sedation-analgesia quality feedback to ICUs did not appear to improve any quality metrics, probably because staff did not think it relevant to bedside practice. FUNDING Chief Scientist Office, Scotland; GE Healthcare.
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Affiliation(s)
- Timothy S Walsh
- Anaesthetics, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, Scotland, UK.
| | - Kalliopi Kydonaki
- Anaesthetics, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, Scotland, UK; Edinburgh Napier University, Edinburgh, Scotland, UK
| | - Jean Antonelli
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, Scotland, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, Scotland, UK
| | - Robert J Lee
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, Scotland, UK
| | - Kirsty Everingham
- Anaesthetics, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, Scotland, UK
| | - Janet Hanley
- Edinburgh Napier University, Edinburgh, Scotland, UK; Edinburgh Health Services Research Unit, Edinburgh, Scotland, UK
| | - Emma C Phillips
- Anaesthetics, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, Scotland, UK
| | - Kimmo Uutela
- GE Healthcare Finland Oy, Kuortaneenkatu 2, 00510 Helsinki, Finland
| | - Petra Peltola
- GE Healthcare Finland Oy, Kuortaneenkatu 2, 00510 Helsinki, Finland
| | - Stephen Cole
- Department of Anaesthetics, Ninewells Hospital, NHS Tayside, Scotland, UK
| | - Tara Quasim
- University Department of Anaesthetics, Glasgow University, Glasgow Royal Infirmary, Glasgow, Scotland, UK
| | - James Ruddy
- Department of Anaesthetics, Monklands Hospital, NHS Lanarkshire, Scotland, UK
| | - Marcia McDougall
- Department of Anaesthetics, Victoria Hospital, Kirkcaldy, NHS Fife, Scotland, UK
| | - Alan Davidson
- Department of Anaesthetics, Victoria Infirmary, NHS GGC, Glasgow, Scotland, UK
| | - John Rutherford
- Department of Anaesthetics, Dumfries and Galloway Royal Infirmary, NHS Dumfries and Galloway, Scotland, UK
| | - Jonathan Richards
- Department of Anaesthetics, Forth Valley Royal Hospital, NHS Forth Valley, Scotland, UK
| | - Christopher J Weir
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, Scotland, UK; Edinburgh Health Services Research Unit, Edinburgh, Scotland, UK
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436
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Abstract
For more than two decades, sepsis was defined as a microbial infection that produces fever (or hypothermia), tachycardia, tachypnoea and blood leukocyte changes. Sepsis is now increasingly being considered a dysregulated systemic inflammatory and immune response to microbial invasion that produces organ injury for which mortality rates are declining to 15-25%. Septic shock remains defined as sepsis with hyperlactataemia and concurrent hypotension requiring vasopressor therapy, with in-hospital mortality rates approaching 30-50%. With earlier recognition and more compliance to best practices, sepsis has become less of an immediate life-threatening disorder and more of a long-term chronic critical illness, often associated with prolonged inflammation, immune suppression, organ injury and lean tissue wasting. Furthermore, patients who survive sepsis have continuing risk of mortality after discharge, as well as long-term cognitive and functional deficits. Earlier recognition and improved implementation of best practices have reduced in-hospital mortality, but results from the use of immunomodulatory agents to date have been disappointing. Similarly, no biomarker can definitely diagnose sepsis or predict its clinical outcome. Because of its complexity, improvements in sepsis outcomes are likely to continue to be slow and incremental.
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Affiliation(s)
- Richard S Hotchkiss
- Department of Anesthesiology, Washington University of St. Louis, St. Louis, Missouri, USA
| | - Lyle L Moldawer
- Department of Surgery, University of Florida College of Medicine, Shands Hospital, Room 6116, 1600 SW Archer Road, Gainesville, Florida 32610-0019, USA
| | - Steven M Opal
- Department of Infectious Diseases and Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Konrad Reinhart
- Department of Anesthesiology and Intensive Care, Jena University Hospital, Jena, Germany
| | - Isaiah R Turnbull
- Department of Anesthesiology, Washington University of St. Louis, St. Louis, Missouri, USA
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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437
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Walsh TS, Salisbury L, Donaghy E, Ramsay P, Lee R, Rattray J, Lone N. PReventing early unplanned hOspital readmission aFter critical ILlnEss (PROFILE): protocol and analysis framework for a mixed methods study. BMJ Open 2016; 6:e012590. [PMID: 27354086 PMCID: PMC4932276 DOI: 10.1136/bmjopen-2016-012590] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Survivors of critical illness experience multidimensional disabilities that reduce quality of life, and 25-30% require unplanned hospital readmission within 3 months following index hospitalisation. We aim to understand factors associated with unplanned readmission; develop a risk model to identify intensive care unit (ICU) survivors at highest readmission risk; understand the modifiable and non-modifiable readmission drivers; and develop a risk assessment tool for identifying patients and areas for early intervention. METHODS AND ANALYSIS We will use mixed methods with concurrent data collection. Quantitative data will comprise linked healthcare records for adult Scottish residents requiring ICU admission (1 January 2000-31 December 2013) who survived to hospital discharge. The outcome will be unplanned emergency readmission within 90 days of index hospital discharge. Exposures will include pre-ICU demographic data, comorbidities and health status, and critical illness variables representing illness severity. Regression analyses will be used to identify factors associated with increased readmission risk, and to develop and validate a risk prediction model. Qualitative data will comprise recorded/transcribed interviews with up to 60 patients and carers recently experiencing unplanned readmissions in three health board regions. A deductive and inductive thematic analysis will be used to identify factors contributing to readmissions and how they may interact. Through iterative triangulation of quantitative and qualitative data, we will develop a construct/taxonomy that captures reasons and drivers for unplanned readmission. We will validate and further refine this in focus groups with patients/carers who experienced readmissions in six Scottish health board regions, and in consultation with an independent expert group. A tool will be developed to screen for ICU survivors at risk of readmission and inform anticipatory interventions. ETHICS AND DISSEMINATION Data linkage has approval but does not require ethical approval. The qualitative study has ethical approval. Dissemination with key healthcare stakeholders and policymakers is planned. TRIAL REGISTRATION NUMBER UKCRN18023.
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Affiliation(s)
- Timothy S Walsh
- University Department of Anaesthesia, Critical Care, and Pain Medicine, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Lisa Salisbury
- University Department of Anaesthesia, Critical Care, and Pain Medicine, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Eddie Donaghy
- University Department of Anaesthesia, Critical Care, and Pain Medicine, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Pamela Ramsay
- University Department of Anaesthesia, Critical Care, and Pain Medicine, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Robert Lee
- Usher Institute, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Janice Rattray
- Department of Nursing Studies, University of Dundee, Dundee, UK
| | - Nazir Lone
- University Department of Anaesthesia, Critical Care, and Pain Medicine, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
- Usher Institute, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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438
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Schmidt K, Worrack S, Von Korff M, Davydow D, Brunkhorst F, Ehlert U, Pausch C, Mehlhorn J, Schneider N, Scherag A, Freytag A, Reinhart K, Wensing M, Gensichen J. Effect of a Primary Care Management Intervention on Mental Health-Related Quality of Life Among Survivors of Sepsis: A Randomized Clinical Trial. JAMA 2016; 315:2703-11. [PMID: 27367877 PMCID: PMC5122319 DOI: 10.1001/jama.2016.7207] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Survivors of sepsis face long-term sequelae that diminish health-related quality of life and result in increased care needs in the primary care setting, such as medication, physiotherapy, or mental health care. OBJECTIVE To examine if a primary care-based intervention improves mental health-related quality of life. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted between February 2011 and December 2014, enrolling 291 patients 18 years or older who survived sepsis (including septic shock), recruited from 9 intensive care units (ICUs) across Germany. INTERVENTIONS Participants were randomized to usual care (n = 143) or to a 12-month intervention (n = 148). Usual care was provided by their primary care physician (PCP) and included periodic contacts, referrals to specialists, and prescription of medication, other treatment, or both. The intervention additionally included PCP and patient training, case management provided by trained nurses, and clinical decision support for PCPs by consulting physicians. MAIN OUTCOMES AND MEASURES The primary outcome was change in mental health-related quality of life between ICU discharge and 6 months after ICU discharge using the Mental Component Summary (MCS) of the 36-Item Short-Form Health Survey (SF-36 [range, 0-100; higher ratings indicate lower impairment; minimal clinically important difference, 5 score points]). RESULTS The mean age of the 291 patients was 61.6 years (SD, 14.4); 66.2% (n = 192) were men, and 84.4% (n = 244) required mechanical ventilation during their ICU stay (median duration of ventilation, 12 days [range, 0-134]). At 6 and 12 months after ICU discharge, 75.3% (n = 219 [112 intervention, 107 control]) and 69.4% (n = 202 [107 intervention, 95 control]), respectively, completed follow-up. Overall mortality was 13.7% at 6 months (40 deaths [21 intervention, 19 control]) and 18.2% at 12 months (53 deaths [27 intervention, 26 control]). Among patients in the intervention group, 104 (70.3%) received the intervention at high levels of integrity. There was no significant difference in change of mean MCS scores (intervention group mean at baseline, 49.1; at 6 months, 52.9; change, 3.79 score points [95% CI, 1.05 to 6.54] vs control group mean at baseline, 49.3; at 6 months, 51.0; change, 1.64 score points [95% CI, -1.22 to 4.51]; mean treatment effect, 2.15 [95% CI, -1.79 to 6.09]; P = .28). CONCLUSIONS AND RELEVANCE Among survivors of sepsis and septic shock, the use of a primary care-focused team-based intervention, compared with usual care, did not improve mental health-related quality of life 6 months after ICU discharge. Further research is needed to determine if modified approaches to primary care management may be more effective. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN61744782.
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Affiliation(s)
- Konrad Schmidt
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstraβe 18, 07743 Jena, Germany
- Center of Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - Susanne Worrack
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstraβe 18, 07743 Jena, Germany
- Center of Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - Michael Von Korff
- Group Health Research Institute, Group Health Cooperative 1730 Minor Avenue, Suite 1600 Seattle, WA 98101, USA
| | - Dimitry Davydow
- Dpt. of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Box 356560 Seattle, WA 98195, USA
| | - Frank Brunkhorst
- Center of Clinical Studies, Dpt. of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Salvador-Allende-Platz 27, 07747 Jena, Germany
- Center of Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - Ulrike Ehlert
- Dpt. of Psychology, University of Zuerich, Binzmuehlenstrasse 14, Box 26, CH-8050 Zuerich, Switzerland
| | - Christine Pausch
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Haertelstraβe 16-18, 04107 Leipzig, Germany
- Center of Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - Juliane Mehlhorn
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstraβe 18, 07743 Jena, Germany
| | - Nico Schneider
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstraβe 18, 07743 Jena, Germany
| | - André Scherag
- Center of Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - Antje Freytag
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstraβe 18, 07743 Jena, Germany
| | - Konrad Reinhart
- Dpt. of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
- Center of Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - Michel Wensing
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstraβe 18, 07743 Jena, Germany
- Radboud University Medical Centre, Radboud Institute of Health Sciences, Geert Grooteplein 9, PO Box 9101, 6500 HB Nijmegen, Netherlands
| | - Jochen Gensichen
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstraβe 18, 07743 Jena, Germany
- Center of Sepsis Control and Care (CSCC), Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
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A qualitative exploration into the long-term perspectives of patients receiving critical care diaries across the United Kingdom. Intensive Crit Care Nurs 2016; 36:1-7. [PMID: 27287736 DOI: 10.1016/j.iccn.2016.04.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 04/26/2016] [Accepted: 04/30/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Increasing evidence suggests the use of a diary with entries by nurses, doctors, AHPs and the patient's family can potentially help by "filling in the gaps" and help the patient make sense of a time that they have forgotten or feel confused and have fears about. AIMS A qualitative exploration of the impact of diaries on critical care patients around the United Kingdom in order to describe the long-term effects of patient diaries. METHODS In-depth qualitative interviews, using principles of grounded theory, via telephone and email were undertaken. The sample included former patients who responded via adverts on critical care charity/support websites. People who had diaries in the previous 1-3 years were asked about their experiences. FINDINGS Eight people who had been patients in various critical care units across the United Kingdom and who had a critical care diary were interviewed. All reported value in having diaries, however, participants reported needing support when first receiving the diary to understand events that took place in critical care. CONCLUSION Diaries can offer a means of filing the gaps for patients who struggle with coming to terms with their critical care recovery, but should be given to patients with forethought and subsequent support.
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Huang M, Parker AM, Bienvenu OJ, Dinglas VD, Colantuoni E, Hopkins RO, Needham DM. Psychiatric Symptoms in Acute Respiratory Distress Syndrome Survivors: A 1-Year National Multicenter Study. Crit Care Med 2016; 44:954-65. [PMID: 26807686 PMCID: PMC4833555 DOI: 10.1097/ccm.0000000000001621] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To evaluate prevalence, severity, and co-occurrence of and risk factors for depression, anxiety, and posttraumatic stress disorder symptoms over the first year after acute respiratory distress syndrome. DESIGN Prospective longitudinal cohort study. SETTINGS Forty-one Acute Respiratory Distress Syndrome Network hospitals across the United States. PATIENTS Six hundred ninety-eight acute respiratory distress syndrome survivors. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Psychiatric symptoms were evaluated by using the Hospital Anxiety and Depression Scale and Impact of Event Scale-Revised at 6 and 12 months. Adjusted prevalence ratios for substantial symptoms (binary outcome) and severity scores were calculated by using Poisson and linear regression, respectively. During 12 months, a total of 416 of 629 patients (66%) with at least one psychiatric outcome measure had substantial symptoms in at least one domain. There was a high and almost identical prevalence of substantial symptoms (36%, 42%, and 24% for depression, anxiety, and posttraumatic stress disorder) at 6 and 12 months. The most common pattern of co-occurrence was having symptoms of all three psychiatric domains simultaneously. Younger age, female sex, unemployment, alcohol misuse, and greater opioid use in the ICU were significantly associated with psychiatric symptoms, whereas greater severity of illness and ICU length of stay were not associated. CONCLUSIONS Psychiatric symptoms occurred in two thirds of acute respiratory distress syndrome survivors with frequent co-occurrence. Sociodemographic characteristics and in-ICU opioid administration, rather than traditional measures of critical illness severity, should be considered in identifying the patients at highest risk for psychiatric symptoms during recovery. Given high co-occurrence, acute respiratory distress syndrome survivors should be simultaneously evaluated for a full spectrum of psychiatric sequelae to maximize recovery.
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Affiliation(s)
- Minxuan Huang
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ann M. Parker
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - O. Joseph Bienvenu
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Victor D. Dinglas
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elizabeth Colantuoni
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Ramona O. Hopkins
- Pulmonary and Critical Care Division, Intermountain Medical Center Department of Medicine, Murray, UT
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT
- Psychology Department and Neuroscience Center, Brigham Young University, Provo, UT
| | - Dale M. Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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441
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Dinglas VD, Hopkins RO, Wozniak AW, Hough CL, Morris PE, Jackson JC, Mendez-Tellez PA, Bienvenu OJ, Ely EW, Colantuoni E, Needham DM. One-year outcomes of rosuvastatin versus placebo in sepsis-associated acute respiratory distress syndrome: prospective follow-up of SAILS randomised trial. Thorax 2016; 71:401-10. [PMID: 26936876 PMCID: PMC6998199 DOI: 10.1136/thoraxjnl-2015-208017] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/05/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Prior randomised trials have evaluated statins in patients with sepsis and acute respiratory distress syndrome (ARDS), but there has been no comprehensive evaluation of long-term effects, despite potential neuromuscular and mental health adverse effects of these drugs. AIM To evaluate the effect of rosuvastatin versus placebo on survival, physical function and performance, and mental health outcomes in patients with sepsis-associated ARDS. METHODS Prospective follow-up evaluation of the ARDS Clinical Trials Network Statins for Acutely Injured Lungs from Sepsis trial of rosuvastatin versus placebo in 568 mechanically ventilated patients with sepsis-associated ARDS, with blinded 6-month outcome assessment performed in the 272 eligible survivors for age-adjusted and sex-adjusted 36-Item Short Form Health Survey (SF-36) physical function and mental health domains, and in 84 eligible survivors for the 6 min walk test, along with secondary outcomes evaluations of survival, and additional patient-reported and performance-based measures at 6-month and 12-month follow-up. RESULTS Over 1-year follow-up, there was no significant difference in cumulative survival in the rosuvastatin versus placebo groups (58% vs 61%; p=0.377), with survivors demonstrating substantial impairments in physical function and mental health. Rosuvastatin versus placebo had no effect (mean treatment effect (95% CI)) on SF-36 physical function (0 (-7 to 8), p=0.939) or mental health (-6 (-12 to 1) p=0.085) domains, 6 min walk distance (per cent predicted: 2 (-9 to 14), p=0.679) or the vast majority of secondary outcomes. CONCLUSIONS Over 1-year follow-up, patients with sepsis-associated ARDS had high cumulative mortality, with survivors commonly experiencing impairments in physical functioning and performance, and mental health. Randomisation to rosuvastatin had no effect on these outcomes. TRIAL REGISTRATION NUMBER NCT00979121 and NCT00719446.
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Affiliation(s)
- Victor D Dinglas
- Outcomes after Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ramona O Hopkins
- Pulmonary and Critical Care Division, Department of Medicine, Intermountain Medical Center, Murray, Utah, USA Psychology Department and Neuroscience Center, Brigham Young University, Provo, Utah, USA Center for Humanizing Critical Care, Intermountain Health Care, Murray, Utah, USA
| | - Amy W Wozniak
- Outcomes after Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Peter E Morris
- Division of Pulmonary, Critical Care & Sleep Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - James C Jackson
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Pedro A Mendez-Tellez
- Outcomes after Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - O Joseph Bienvenu
- Outcomes after Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Elizabeth Colantuoni
- Outcomes after Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Dale M Needham
- Outcomes after Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland, USA Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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442
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Herridge MS, Moss M, Hough CL, Hopkins RO, Rice TW, Bienvenu OJ, Azoulay E. Recovery and outcomes after the acute respiratory distress syndrome (ARDS) in patients and their family caregivers. Intensive Care Med 2016; 42:725-738. [PMID: 27025938 DOI: 10.1007/s00134-016-4321-8] [Citation(s) in RCA: 244] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 03/09/2016] [Indexed: 02/06/2023]
Abstract
Outcomes after acute respiratory distress syndrome (ARDS) are similar to those of other survivors of critical illness and largely affect the nerve, muscle, and central nervous system but also include a constellation of varied physical devastations ranging from contractures and frozen joints to tooth loss and cosmesis. Compromised quality of life is related to a spectrum of impairment of physical, social, emotional, and neurocognitive function and to a much lesser extent discrete pulmonary disability. Intensive care unit-acquired weakness (ICUAW) is ubiquitous and includes contributions from both critical illness polyneuropathy and myopathy, and recovery from these lesions may be incomplete at 5 years after ICU discharge. Cognitive impairment in ARDS survivors ranges from 70 to 100 % at hospital discharge, 46 to 80 % at 1 year, and 20 % at 5 years, and mood disorders including depression and post-traumatic stress disorder (PTSD) are also sustained and prevalent. Robust multidisciplinary and longitudinal interventions that improve these outcomes are still uncertain and data in our literature are conflicting. Studies are needed in family members of ARDS survivors to better understand long-term outcomes of the post-ICU family syndrome and to evaluate how it affects patient recovery.
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Affiliation(s)
- Margaret S Herridge
- Critical Care and Respiratory Medicine, Toronto General Research Institute, University of Toronto, Toronto, ON, Canada.
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Catherine L Hough
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Ramona O Hopkins
- Psychology Department, Brigham Young University, Provo, UT, USA.,Neuroscience Center, Brigham Young University, Provo, UT, USA.,Department of Medicine, Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA.,Center for Humanizing Critical Care, Intermountain Health Care, Murray, UT, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Department of Medicine, Nashville, TN, USA
| | - O Joseph Bienvenu
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elie Azoulay
- Medical ICU of the Saint-Louis Hospital, Paris Diderot Sorbonne University, Paris, France
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443
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Tramm R, Ilic D, Murphy K, Sheldrake J, Pellegrino V, Hodgson C. A qualitative exploration of acute care and psychological distress experiences of ECMO survivors. Heart Lung 2016; 45:220-6. [PMID: 26916455 DOI: 10.1016/j.hrtlng.2016.01.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 01/23/2016] [Accepted: 01/26/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To explore the acute care experience of extracorporeal membrane oxygenation (ECMO) patients. BACKGROUND ECMO is used in life-threatening scenarios of acute lung or heart failure. The patient's experience with ECMO treatment and the psychological distress are unknown. METHODS Qualitative analysis of semi-structured interviews with ECMO survivors 12 months after discharge were conducted and thematically analyzed. RESULTS Ten participants treated with ECMO for life-threatening acute heart or lung failure were interviewed. Six themes that captured the ICU experience of ECMO patients were identified including; dealing with crisis, critical care, memory, role of significant others and existence today and tomorrow. Deconditioning was the most frequently reported experience. Patchy factual memories contrasted with detailed delirious memories and paranoid ideations. CONCLUSION Patients treated with ECMO experienced deconditioning, perceived threats of serious injury or death and delusional episodes with recalls of psychological distress.
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Affiliation(s)
- Ralph Tramm
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Centre L6, 99 Commercial Rd, Prahran, 3004 Melbourne, Australia.
| | - Dragan Ilic
- Department of Epidemiology and Preventive Medicine (DEPM), Monash University, The Alfred Centre L6, 99 Commercial Rd, Prahran, 3004 Melbourne, Australia
| | - Kerry Murphy
- Department of Epidemiology and Preventive Medicine (DEPM), Monash University, The Alfred Centre L6, 99 Commercial Rd, Prahran, 3004 Melbourne, Australia
| | - Jayne Sheldrake
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Commercial Rd, Prahran, 3004 Melbourne, Australia
| | - Vincent Pellegrino
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Commercial Rd, Prahran, 3004 Melbourne, Australia
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Centre L6, 99 Commercial Rd, Prahran, 3004 Melbourne, Australia
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444
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445
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Nikayin S, Rabiee A, Hashem MD, Huang M, Bienvenu OJ, Turnbull AE, Needham DM. Anxiety symptoms in survivors of critical illness: a systematic review and meta-analysis. Gen Hosp Psychiatry 2016; 43:23-29. [PMID: 27796253 PMCID: PMC5289740 DOI: 10.1016/j.genhosppsych.2016.08.005] [Citation(s) in RCA: 266] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 08/20/2016] [Accepted: 08/24/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To evaluate the epidemiology of and postintensive care unit (ICU) interventions for anxiety symptoms after critical illness. METHODS We searched five databases (1970-2015) to identify studies assessing anxiety symptoms in adult ICU survivors. Data from studies using the most common assessment instrument were meta-analyzed. RESULTS We identified 27 studies (2880 patients) among 27,334 citations. The Hospital Anxiety and Depression Scale-Anxiety (HADS-A) subscale was the most common instrument (81% of studies). We pooled data at 2-3, 6 and 12-14month time-points, with anxiety symptom prevalences [HADS-A≥8, 95% confidence interval (CI)] of 32%(27-38%), 40%(33-46%) and 34%(25-42%), respectively. In a subset of studies with repeated assessments in the exact same patients, there was no significant change in anxiety score or prevalence over time. Age, gender, severity of illness, diagnosis and length of stay were not associated with anxiety symptoms. Psychiatric symptoms during admission and memories of in-ICU delusional experiences were potential risk factors. Physical rehabilitation and ICU diaries had potential benefit. CONCLUSIONS One third of ICU survivors experience anxiety symptoms that are persistent during their first year of recovery. Psychiatric symptoms during admission and memories of in-ICU delusional experiences were associated with post-ICU anxiety. Physical rehabilitation and ICU diaries merit further investigation as possible interventions.
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Affiliation(s)
- Sina Nikayin
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Anahita Rabiee
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Mohamed D. Hashem
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Minxuan Huang
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - O. Joseph Bienvenu
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD,Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Alison E. Turnbull
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD,Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Dale M. Needham
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD,Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore
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446
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Altmann U, Zimmermann A, Kirchmann HA, Kramer D, Fembacher A, Bruckmayer E, Pfaffinger I, von Heymann F, Auch E, Steyer R, Strauss BM. Outpatient Psychotherapy Reduces Health-Care Costs: A Study of 22,294 Insurants over 5 Years. Front Psychiatry 2016; 7:98. [PMID: 27378950 PMCID: PMC4904013 DOI: 10.3389/fpsyt.2016.00098] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 05/25/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The project "Quality Assurance in Ambulatory Psychotherapy in Bavaria" (QS-PSY-BAY) focuses on the quality assurance of outpatient psychotherapy (OPT) in Germany in terms of symptom reduction and cost reduction under naturalistic conditions. In this study, we examined the effectiveness of psychotherapy in terms of pre-post cost reduction. METHOD The health-care costs of N = 22,294 insurants over a 5-year period were examined in a naturalistic longitudinal design. Six participating health insurance funds provided data on costs related to inpatient treatment, outpatient treatment, drugs, and hospitalization and work disability days. RESULTS We found that the average annual total costs for inpatient and outpatient treatments as well as drug costs and work disability days increased from the second to the first year before OPT. Besides a large and significant reduction of work disability days (41.8%), hospitalization days (27.4%), and inpatient costs (21.5%) from the first year before versus the first year following OPT, we found evidence for long-term effects: the number of work disability days in the second year after OPT was lower (23.8%), and drug costs were higher than in the second year before OPT (41.5%). CONCLUSION We conclude that OPT as a part of the health insurance system is an investment which can pay off in the future especially in terms of lower inpatient costs and work disability.
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Affiliation(s)
- Uwe Altmann
- Institute of Psychosocial Medicine and Psychotherapy, University Hospital Jena , Jena , Germany
| | - Anna Zimmermann
- Institute of Psychosocial Medicine and Psychotherapy, University Hospital Jena , Jena , Germany
| | - Helmut A Kirchmann
- Institute of Psychosocial Medicine and Psychotherapy, University Hospital Jena , Jena , Germany
| | - Dietmar Kramer
- Bavarian Association of Statutory Health Insurance Physicians , Munich , Germany
| | - Andrea Fembacher
- Bavarian Association of Statutory Health Insurance Physicians , Munich , Germany
| | | | - Irmgard Pfaffinger
- Medical Specialist for Psychosomatic Medicine and Psychotherapy in Private Practice , Munich , Germany
| | | | - Emma Auch
- Medical Specialist for Psychosomatic Medicine and Psychotherapy in Private Practice , Munich , Germany
| | - Rolf Steyer
- Institute of Psychology, Friedrich-Schiller-University Jena , Jena , Germany
| | - Bernhard M Strauss
- Institute of Psychosocial Medicine and Psychotherapy, University Hospital Jena , Jena , Germany
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447
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Flaigle MC, Ascenzi J, Kudchadkar SR. Identifying Barriers to Delirium Screening and Prevention in the Pediatric ICU: Evaluation of PICU Staff Knowledge. J Pediatr Nurs 2016; 31:81-4. [PMID: 26362671 PMCID: PMC4724532 DOI: 10.1016/j.pedn.2015.07.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 07/24/2015] [Accepted: 07/24/2015] [Indexed: 12/16/2022]
Abstract
Delirium in the pediatric intensive care unit (PICU) setting is often unrecognized and undertreated. The importance of screening and identification of ICU delirium has been identified in both adult and pediatric literature. Delirium increases ICU morbidity, length of mechanical ventilation and length of stay. The objective of this study was to determine the current knowledge level about delirium and its risk factors among pediatric critical care nurses through a short questionnaire. We hypothesized that before a targeted educational intervention, PICU care providers do not have an adequate knowledge base for accurate screening and diagnosis of delirium in critically ill children. A 17 question online survey was given to all nurses in a tertiary 36-bed PICU to assess current knowledge about delirium in children. The response rate was 73% (105/143). When asked to identify the correct way to diagnose pediatric delirium, 11.4% of nurses surveyed (12/105) incorrectly believed that Glasgow Coma Score is the appropriate screening tool. A large proportion of respondents (40/105) believed that benzodiazepines are helpful in treatment of delirium. The results of the survey identified specific knowledge gaps about risk factors and treatment of pediatric delirium in the critically ill child. There is a critical need for education about pediatric delirium and its risk factors among PICU staff prior to unit-wide implementation of a delirium screening and prevention program, specifically with regards to screening methods and pharmacologic risk factors. These results are likely generalizable to all physicians, nurses and staff who care for critically ill children.
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Affiliation(s)
- Melanie Cooper Flaigle
- Department of Anesthesiology and Critical Care Medicine & Pediatrics, Johns Hopkins University, Maryland
| | | | - Sapna R Kudchadkar
- Department of Anesthesiology and Critical Care Medicine & Pediatrics, Johns Hopkins University, Maryland.
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448
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Protocolized sedation effect on post-ICU posttraumatic stress disorder prevalence: A systematic review and network meta-analysis. J Crit Care 2015; 30:1278-82. [PMID: 26315653 DOI: 10.1016/j.jcrc.2015.07.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/05/2015] [Accepted: 07/22/2015] [Indexed: 12/28/2022]
Abstract
PURPOSE Strategies aiming light sedation are associated with decreased length on mechanical ventilation. However, awake or easily arousable patients may be prone to greater prevalence of posttraumatic stress disorder (PTSD). These systematic review and meta-analysis aimed to evaluate the safety of light sedation strategies regarding the prevalence of PTSD. METHODS We searched MEDLINE, Scopus, and Web of Science from inception to November 2014 for randomized controlled trials that evaluated light sedation strategies and addressed PTSD prevalence in the follow-up as a specific outcome. Because not all trials performed the same comparisons, we performed a network meta-analysis to evaluate indirect comparisons. RESULTS Five studies fulfilled our inclusion criteria and were included in the meta-analysis. Two studies compared daily sedation interruption with usual care (92 patients), 2 studies compared a light sedation protocol with daily sedation interruption (47 patients), and 1 study compared light and deep sedation (102 patients). Compared with usual sedation care/deep sedation, neither daily interruption of sedation (odds ratio=0.66; 95% confidence interval, 0.22-1.98) nor a light sedation protocol (odds ratio=0.90, 95% confidence interval, 0.27-3.05) was associated with increased risks on long-term PTSD prevalence. CONCLUSION Light sedation strategies seem to be safe in terms of PTSD prevalence. However, the small number of included trials and patients may not be sufficient to drive strong statements.
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449
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Posttraumatic stress disorder in critical illness survivors: too many questions remain. Crit Care Med 2015; 43:1151-2. [PMID: 25876122 DOI: 10.1097/ccm.0000000000000896] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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