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Chichra A, Tickoo M, Honiden S. Managing the Chronically Ventilated Critically Ill Population. J Intensive Care Med 2024; 39:703-714. [PMID: 37787184 DOI: 10.1177/08850666231203601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Advances in intensive care over the past few decades have significantly improved the chances of survival for patients with acute critical illness. However, this progress has also led to a growing population of patients who are dependent on intensive care therapies, including prolonged mechanical ventilation (PMV), after the initial acute period of critical illness. These patients are referred to as the "chronically critically ill" (CCI). CCI is a syndrome characterized by prolonged mechanical ventilation, myoneuropathies, neuroendocrine disorders, nutritional deficiencies, cognitive and psychiatric issues, and increased susceptibility to infections. It is associated with high morbidity and mortality as well as a significant increase in healthcare costs. In this article, we will review disease burden, outcomes, psychiatric effects, nutritional and ventilator weaning strategies as well as the role of palliative care for CCI with a specific focus on those requiring PMV.
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Affiliation(s)
- Astha Chichra
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mayanka Tickoo
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Shyoko Honiden
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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Shaikh H, Ionita R, Khan U, Park Y, Jubran A, Tobin MJ, Laghi F. Effect of Atypical Sleep EEG Patterns on Weaning From Prolonged Mechanical Ventilation. Chest 2024; 165:1111-1119. [PMID: 38211699 PMCID: PMC11214907 DOI: 10.1016/j.chest.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 12/22/2023] [Accepted: 01/03/2024] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Approximately one-third of acute ICU patients display atypical sleep patterns that cannot be interpreted by using standard EEG criteria for sleep. Atypical sleep patterns have been associated with poor weaning outcomes in acute ICUs. RESEARCH QUESTION Do patients being weaned from prolonged mechanical ventilation experience atypical sleep EEG patterns, and are these patterns linked with weaning outcomes? STUDY DESIGN AND METHODS EEG power spectral analysis during wakefulness and overnight polysomnogram were performed on alert, nondelirious patients at a long-term acute care facility. RESULTS Forty-four patients had been ventilated for a median duration of 38 days at the time of the polysomnogram study. Eleven patients (25%) exhibited atypical sleep EEG. During wakefulness, relative EEG power spectral analysis revealed higher relative delta power in patients with atypical sleep than in patients with usual sleep (53% vs 41%; P < .001) and a higher slow-to-fast power ratio during wakefulness: 4.39 vs 2.17 (P < .001). Patients with atypical sleep displayed more subsyndromal delirium (36% vs 6%; P = .027) and less rapid eye movement sleep (4% vs 11% total sleep time; P < .02). Weaning failure was more common in the atypical sleep group than in the usual sleep group: 91% vs 45% (P = .013). INTERPRETATION This study provides the first evidence that patients in a long-term acute care facility being weaned from prolonged ventilation exhibit atypical sleep EEG patterns that are associated with weaning failure. Patients with atypical sleep EEG patterns had higher rates of subsyndromal delirium and slowing of the wakeful EEG, suggesting that these two findings represent a biological signal for brain dysfunction.
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Affiliation(s)
- Hameeda Shaikh
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, IL
| | - Ramona Ionita
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, IL
| | - Usman Khan
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, IL
| | - Youngsook Park
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, IL
| | - Amal Jubran
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, IL; RML Specialty Hospital, Hinsdale, IL
| | - Martin J Tobin
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, IL.
| | - Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, IL; RML Specialty Hospital, Hinsdale, IL
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Zhao L, Xu WK, Wang Y, Lu WY, Wu Y, Hu R. Development and clinical empirical validation of the chronic critical illness prognosis prediction model. Technol Health Care 2024; 32:977-987. [PMID: 37545280 DOI: 10.3233/thc-230359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
BACKGROUND The evolution of critical care medicine and nursing has aided and enabled the rescue of a large number of patients from numerous life-threatening diseases. However, in many cases, patient health may not be quickly restored, and the long-term prognosis may not be optimistic. OBJECTIVES In this study, we aimed to develop and validate a prediction model for accurate, precise, and objective identification of the severity of chronic critical illness (CCI) in patients. METHODS We used a retrospective case-control and prospective cohort study with no interventions. Patients diagnosed with CCI admitted to the ICU of a large metropolitan public hospital were selected. In the case-control study, 344 patients (case: 172; control:172) were enrolled to develop the prognosis prediction model of chronic critical illness (PPCCI Model); 88 patients (case:44; control: 44) in a prospective cohort study, served as the validation cohort. The discrimination of the model was measured using the area under the curve (AUC) of the receiver operating characteristic curve (ROC). RESULTS Age, prolonged mechanical ventilation (PMV), sepsis or other severe infections, Glasgow Coma Scale (GCS), mean artery pressure (MAP), heart rate (HR), respiratory rate (RR), oxygenation index (OI), and active bleeding were the nine predictors included in the model. In both cohorts, the PPCCI model outperformed the Acute Physiology And Chronic Health Evaluation II (APACHE II), Modified Early Warning Score (MEWS), and Sequential Organ Failure Assessment (SOFA) in identifying deceased patients with CCI (development cohort: AUC, 0.934; 95%CI, 0.908-0.960; validation cohort: AUC, 0.965; 95% CI, 0.931-0.999). CONCLUSION The PPCCI model can provide ICU medical staff with a standardized measurement tool for assessing the condition of patients with CCI, enabling them to allocate ward monitoring resources rationally and communicate with family members.
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Affiliation(s)
- Li Zhao
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
- Intensive Care Unit, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Wen-Kui Xu
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
| | - Ying Wang
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
| | - Wei-Yan Lu
- Department of Orthopaedic Trauma, Foot and Ankle Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yong Wu
- Department of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Rong Hu
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
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Roccasecca Sampaio Gaia V, Costa ELV, Yamaguti WP, Francisco DDS, Fumis RRL. Functional recovery of chronically critically ill patients in the first days after discharge from the intensive care unit: Feasibility of the 6-minute step test. PLoS One 2023; 18:e0293747. [PMID: 37917777 PMCID: PMC10621841 DOI: 10.1371/journal.pone.0293747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Survivors of chronic critical illness often experience weakness and functional dependence to various degrees after their intensive care unit (ICU) stay. Evaluating their functional status with the traditional six-minute walk test is challenging due to space constraints or patient intolerance. OBJECTIVE Our aim was to evaluate the feasibility of using the six-minute step test (6MST) as a measure of functional capacity in chronically critically ill patients early after ICU discharge. METHODS This prospective study was undertaken in a private Brazilian hospital. From July 2019 to July 2020, all chronically critically ill patients were asked to participate 48 hours after ICU discharge. On the day of study inclusion and a week later, those who consented underwent functional assessment comprised of the 6MST, peripheral muscle strength using handgrip strength (HGS), and mobility using the ICU mobility scale (IMS). RESULTS A total of 40 patients were included. The 6MST was feasible in 40% on the first evaluation and 57% on the second. The median 6MST was 0 [0-5] on the first evaluation and 3.5 [0-7.75] on the second (P = 0.005). The median HGS increased from 11.50 [9.25-18] on the first evaluation to 14.5 [10-20] on the second (P = 0.006). The median IMS was 4.5 [3.25-7] on the first evaluation and 6 [3.25-7] on the second (P<0.001). Despite the significant improvement, all parameters measured remained well below normal. CONCLUSION The 6MST was a feasible measure of functional capacity in chronically critically ill patients early after ICU discharge. Patients had functional capacity well below predicted values.
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Affiliation(s)
| | - Eduardo Leite Vieira Costa
- Laboratório de Pneumologia LIM-09, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
- Research and Education Institute, Hospital Sírio-Libanes, Sao Paulo, São Paulo, Brazil
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Huang C, Wu TH, Chen JC. End-of-Life Decisions of Intracranial Hemorrhage Patients Successfully Weaned From Prolonged Mechanical Ventilation. Am J Hosp Palliat Care 2022; 39:1342-1349. [PMID: 35333660 PMCID: PMC9527450 DOI: 10.1177/10499091221074636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Factors related to the end-of-life decisions of patients with intracranial hemorrhage who were successfully weaned from prolonged mechanical ventilation remain unclear. This study aimed to evaluate factors that influence the end-of-life decisions of these patients. METHODS This retrospective study examined patients with intracranial hemorrhage successfully weaned from prolonged mechanical ventilation between January 2012 and December 2017. The following data was collected and analyzed: age, gender, comorbidities, Glasgow Coma Scale scores, receipt or non-receipt of intracranial hemorrhage surgery, discharge status, and end-of-life decisions. RESULTS In total, 91 patients with intracranial hemorrhage were successfully weaned from prolonged mechanical ventilation. The families of 62 (68.1%) patients signed the do-not-resuscitate order. A Glasgow Coma Scale score of ≥10 at discharge from the respiratory care center and zero comorbidities were the influencing factors between patients whose do-not-resuscitate orders were signed and those whose orders were not signed. Patients with intracranial hemorrhage successfully weaned from prolonged mechanical ventilation had chronic kidney disease comorbidity and Glasgow Coma Scale score of <7 on admission to respiratory care center with a general ward mortality rate of 83.3%. CONCLUSIONS The families of intracranial hemorrhage patients with multiple comorbidities and higher neurologic impairment after successful weaning from the ventilator believed that palliative therapy would provide a greater benefit. Patients with intracranial hemorrhage successfully weaned from prolonged mechanical ventilation with chronic kidney disease comorbidity and Glasgow Coma Scale score of <7 on admission to respiratory care center are candidates for the consideration of hospice care with ventilator withdrawal.
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Affiliation(s)
- Chienhsiu Huang
- Department of Internal medicine, Division of Chest Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Tsung-Hsien Wu
- Department of Surgery, Division of Neurosurgery, Dalin Tzu Chi Hospital, Chia-Yi, Taiwan and school of medicine, Tzuchi University, Hualien, Taiwan
| | - Jin-Cherng Chen
- Department of Surgery, Division of Neurosurgery, Dalin Tzu Chi Hospital, Chia-Yi, Taiwan and school of medicine, Tzuchi University, Hualien, Taiwan
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Shi HJ, Yuan RX, Zhang JZ, Chen JH, Hu AM. Effect of midazolam on delirium in critically ill patients: a propensity score analysis. J Int Med Res 2022; 50:3000605221088695. [PMID: 35466751 PMCID: PMC9044793 DOI: 10.1177/03000605221088695] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To observe the association between exposure to midazolam within 24 hours prior to delirium assessment and the risk of delirium. Methods We performed a systematic cohort study with two sets of cohorts to estimate the relative risks of outcomes among patients administered midazolam within 24 hours prior to delirium assessment. Propensity score matching was performed to generate a balanced 1:1 matched cohort and identify potential prognostic factors. The outcomes included the odds of delirium, mortality, length of intensive care unit stay, length of hospitalization, and odds of being discharged home. Results A total of 78,364 patients were included in this study, of whom 22,159 (28.28%) had positive records. Propensity matching successfully balanced covariates for 9348 patients (4674 per group). Compared with no administration of midazolam, midazolam administration was associated with a significantly higher risk of delirium, higher mortality, and a longer intensive care unit stay. Patients treated with midazolam were relatively less likely to be discharged home. There was no significant difference in hospitalization duration. Conclusions Midazolam may be an independent risk factor for delirium in critically ill patients.
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Affiliation(s)
- He-Jie Shi
- Department of Anesthesiology, Shenzhen People’s Hospital, Shenzhen, China
- The Second Clinical Medical College, Jinan University, Shenzhen, China
- First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Rui-Xia Yuan
- Department of Anesthesiology, Shenzhen People’s Hospital, Shenzhen, China
- The Second Clinical Medical College, Jinan University, Shenzhen, China
- First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Jun-Zhi Zhang
- Department of Anesthesiology, Shenzhen People’s Hospital, Shenzhen, China
- The Second Clinical Medical College, Jinan University, Shenzhen, China
- First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - Jia-Hui Chen
- Department of Anesthesiology, Shenzhen People’s Hospital, Shenzhen, China
- The Second Clinical Medical College, Jinan University, Shenzhen, China
- First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
| | - An-Min Hu
- Department of Anesthesiology, Shenzhen People’s Hospital, Shenzhen, China
- The Second Clinical Medical College, Jinan University, Shenzhen, China
- First Affiliated Hospital, Southern University of Science and Technology, Shenzhen, China
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Ballesteros MÁ, Sánchez‐Arguiano MJ, Chico‐Fernández M, Barea‐Mendoza JA, Serviá‐Goixart L, Sánchez‐Casado M, García Sáez I, Pino‐Sánchez FI, Antonio Llompart‐Pou J, Miñambres E. Chronic critical illness in polytrauma. Results of the Spanish trauma in ICU registry. Acta Anaesthesiol Scand 2022; 66:722-730. [PMID: 35332519 DOI: 10.1111/aas.14065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 02/11/2022] [Accepted: 03/08/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Chronic critical illness after trauma injury has not been fully evaluated, and there is little evidence in this regard. We aim to describe the prevalence and risk factors of chronic critical illness (CCI) in trauma patients admitted to the intensive care unit. MATERIAL AND METHODS Retrospective observational multicenter study (Spanish Registry of Trauma in ICU (RETRAUCI)). Period March 2015 to December 2019. Trauma patients admitted to the ICU, who survived the first 48 h, were included. Chronic critical illness (CCI) was considered as the need for mechanical ventilation for a period greater than 14 days and/or placement of a tracheostomy. The main outcomes measures were prevalence and risk factors of CCI after trauma. RESULTS 1290/9213 (14%) patients developed CCI. These patients were older (51.2 ± 19.4 vs 49 ± 18.9); p < .01) and predominantly male (79.9%). They presented a higher proportion of infectious complications (81.3% vs 12.7%; p < .01) and multiple organ dysfunction syndrome (MODS) (27.02% vs 5.19%; p < .01). CCI patients required longer stays in the ICU and had higher ICU and overall in-hospital mortality. Age, injury severity score, head injury, infectious complications, and development of MODS were independent predictors of CCI. CONCLUSION CCI in trauma is a prevalent entity in our series. Early identification could facilitate specific interventions to change the trajectory of this process.
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Affiliation(s)
| | | | - Mario Chico‐Fernández
- UCI de Trauma y Emergencias Servicio de Medicina Intensiva, Hospital Universitario Madrid Spain
| | | | - Luis Serviá‐Goixart
- Servicio de Medicina Intensiva Hospital Universitario Arnau de Vilanova Lleida Spain
| | | | - Iker García Sáez
- Servicio de Medicina Intensiva Hospital Universitario Donostia Donostia‐San Sebastian Spain
| | | | - Juan Antonio Llompart‐Pou
- Servei de Medicina Intensiva Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears (IdISBa) Palma Spain
| | - Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care University Hospital Marqués de Valdecilla‐IDIVAL School of Medicine University of Cantabria Santander Spain
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Remote Monitoring of Chronic Critically Ill Patients after Hospital Discharge: A Systematic Review. J Clin Med 2022; 11:jcm11041010. [PMID: 35207287 PMCID: PMC8879658 DOI: 10.3390/jcm11041010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/29/2022] [Accepted: 02/11/2022] [Indexed: 12/22/2022] Open
Abstract
Background: Over the past few decades, critical care has seen many advancements. These advancements resulted in a considerable increase in the prevalence of chronically critically ill patients requiring prolonged medical care, which led to a massive increase in healthcare utilization. Methods: We performed a search for suitable articles using PubMed and Google Scholar from the inception of these databases to 15 May 2021. Results: Thirty-four articles were included in the review and analyzed. We described the following characteristics and problems with chronic critically ill patient management: the patient population, remote monitoring, the monitoring of physiological parameters in chronic critically ill patients, the anatomical location of sensors, the barriers to implementation, and the main technology-related issues. The main challenges in the management of these patients are (1) the shortage of caretakers, (2) the periodicity of vital function monitoring (e.g., episodic measuring of blood pressure leads to missing important critical events such as hypertension, hypotension, and hypoxia), and (3) failure to catch and manage critical physiological events at the right time, which can result in poor outcomes. Conclusions: The prevalence of critically ill patients is expected to grow. Technical solutions can greatly assist medical personnel and caregivers. Wearable devices can be used to monitor blood pressure, heart rate, pulse, respiratory rate, blood oxygen saturation, metabolism, and central nervous system function. The most important points that should be addressed in future studies are the performance of the remote monitoring systems, safety, clinical and economic outcomes, as well as the acceptance of the devices by patients, caretakers, and healthcare professionals.
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Detailed Characterization of Brain Dysfunction in a Long-Term Rodent Model of Critical Illness. Neurochem Res 2021; 47:613-621. [PMID: 34674138 DOI: 10.1007/s11064-021-03470-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/13/2021] [Accepted: 10/16/2021] [Indexed: 10/20/2022]
Abstract
Critical illness encompasses a wide spectrum of life-threatening clinical conditions requiring intensive care. Our objective was to evaluate cognitive, inflammatory and cellular metabolism alterations in the central nervous system in an animal model of critical illness induced by zymosan. For this Wistar rats that were divided into Sham and zymosan. Zymozan was administered once intraperitoneally (30 g/100 g body weight) diluted in mineral oil. The animals were submitted to behavioral tests of octagonal maze, inhibitory avoidance and elevated plus maze. Brain structures (cortex, prefrontal and hippocampus) were removed at 24 h, 4, 7 and 15 days after zymosan administration for analysis of cytokine levels (TNF-α, IL-1b, IL-6 and IL-10), oxidative damage and oxygen consumption. Zymosan-treated animals presented mild cognitive impairment both in aversive (inhibitory avoidance) and non-aversive (octagonal maze) tasks by day 15. However, they did not show increase in anxiety (elevated-plus maze). The first neurochemical alteration found was an increase in brain pro-inflammatory cytokines (IL-1β, IL-6 and TNF-α) at day 4th in the hippocampus. In cortex, a late (7 and 15 days) increase in TNF-α was also noted, while the anti-inflammatory cytokine IL-10 decrease from 4 to 15 days. Oxygen consumption was decreased in the hippocampus and pre-frontal, but not cortex, only at 7 days. Additionally, it was observed a late (15 days) increase in oxidative damage parameters. This characterization of brain dysfunction in rodent model of critical illness reproduces some of the alterations reported in humans such neuropsychiatric disorders, especially depression, memory loss and cognitive changes and can add to the nowadays used models.
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George N, Moseley E, Eber R, Siu J, Samuel M, Yam J, Huang K, Celi LA, Lindvall C. Deep learning to predict long-term mortality in patients requiring 7 days of mechanical ventilation. PLoS One 2021; 16:e0253443. [PMID: 34185798 PMCID: PMC8241081 DOI: 10.1371/journal.pone.0253443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 06/06/2021] [Indexed: 01/12/2023] Open
Abstract
Background Among patients with acute respiratory failure requiring prolonged mechanical ventilation, tracheostomies are typically placed after approximately 7 to 10 days. Yet half of patients admitted to the intensive care unit receiving tracheostomy will die within a year, often within three months. Existing mortality prediction models for prolonged mechanical ventilation, such as the ProVent Score, have poor sensitivity and are not applied until after 14 days of mechanical ventilation. We developed a model to predict 3-month mortality in patients requiring more than 7 days of mechanical ventilation using deep learning techniques and compared this to existing mortality models. Methods Retrospective cohort study. Setting: The Medical Information Mart for Intensive Care III Database. Patients: All adults requiring ≥ 7 days of mechanical ventilation. Measurements: A neural network model for 3-month mortality was created using process-of-care variables, including demographic, physiologic and clinical data. The area under the receiver operator curve (AUROC) was compared to the ProVent model at predicting 3 and 12-month mortality. Shapley values were used to identify the variables with the greatest contributions to the model. Results There were 4,334 encounters divided into a development cohort (n = 3467) and a testing cohort (n = 867). The final deep learning model included 250 variables and had an AUROC of 0.74 for predicting 3-month mortality at day 7 of mechanical ventilation versus 0.59 for the ProVent model. Older age and elevated Simplified Acute Physiology Score II (SAPS II) Score on intensive care unit admission had the largest contribution to predicting mortality. Discussion We developed a deep learning prediction model for 3-month mortality among patients requiring ≥ 7 days of mechanical ventilation using a neural network approach utilizing readily available clinical variables. The model outperforms the ProVent model for predicting mortality among patients requiring ≥ 7 days of mechanical ventilation. This model requires external validation.
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Affiliation(s)
- Naomi George
- Department of Emergency Medicine, Division of Critical Care, University of New Mexico Health Science Center, Albuquerque, New Mexico, United States of America
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
| | - Edward Moseley
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America
| | - Rene Eber
- Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- Université de Montpellier, Montpellier, France
| | - Jennifer Siu
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Otolaryngology, Division of Head & Neck Surgery, University of Toronto, Toronto, Canada
| | - Mathew Samuel
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Jonathan Yam
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Kexin Huang
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Leo Anthony Celi
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Massachusetts Institute of Technology, Cambridge, Massachusetts, United States of America
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Charlotta Lindvall
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
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Functional Outcomes, Goals, and Goal Attainment Amongst Chronically Critically Ill Long-Term Acute Care Hospital Patients. Ann Am Thorac Soc 2021; 18:2041-2048. [PMID: 33984248 DOI: 10.1513/annalsats.202011-1412oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
RATIONALE Chronically critically ill patients admitted to a long-term acute care hospital (LTACH) setting are a vulnerable population of intensive care unit survivors. Little is known of the goals and functional outcomes achieved by patients after rehabilitation in the LTACH setting. OBJECTIVES We sought to examine patient goals and functional outcomes, including swallowing function, amongst ICU survivors admitted to an LTACH with a tracheostomy. METHODS Prospective observational cohort study of chronic critically ill LTACH patients. RESULTS Fifty elderly subjects with a median duration of intubation prior to tracheostomy of 13 days were enrolled. ICU-acquired weakness and cognitive impairment were present in 40 (80%) and 36 (72%) patients, as measured by the Medical Research Council scale and Montreal Cognitive Assessment, respectively. Mental health problems were also common, with 16 (32%) patients experiencing moderate to severe anxiety, 9 (18%) experiencing moderate to severe depression, and 11 (22%) reporting symptoms consistent with PTSD, according to the Hospital Anxiety and Depression Scale and Post-Traumatic Stress Syndrome 10-Questions Inventory, respectively. Pharyngeal dysfunction, as measured by Fiberoptic Endoscopic Evaluation of Swallow exam, was present in 37 (74%) patients. Patient goals, in decreasing order of frequency, included: eating and drinking, speaking, walking, returning home, and toileting. By LTACH discharge, goal attainment was variable, with 97% of those who ranked speaking as important able to speak, 88% able to eat and drink, yet only 21% were walking and 18% were able to self-toilet. Discharge to the home or acute rehabilitation setting, achieved in 52% of the population, was associated with greater strength, as measured by the total MRC score (p=0.002), as well as the EuroQOL domains of mobility (p=0.008) and self-care (p=0.04). CONCLUSIONS Goal attainment during this period of recovery was variable. The ability to speak, eat and drink, frequently identified as goals by these patients, were achieved, while functional goals such as walking were rarely achieved. These findings highlight the importance of identifying patient goals and setting realistic expectations informed by functional assessments when rehabilitating this vulnerable patient population in the LTACH and subsequent post-acute care settings.
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Cardiovascular and Renal Disease in Chronic Critical Illness. J Clin Med 2021; 10:jcm10081601. [PMID: 33918938 PMCID: PMC8070314 DOI: 10.3390/jcm10081601] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/01/2021] [Accepted: 04/08/2021] [Indexed: 12/29/2022] Open
Abstract
With advances in critical care, patients who would have succumbed in previous eras now survive through hospital discharge. Many survivors suffer from chronic organ dysfunction and induced frailty, representing an emerging chronic critical illness (CCI) phenotype. Persistent and worsening cardiovascular and renal disease are primary drivers of the CCI phenotype and have pathophysiologic synergy, potentiating one another and generating a downward spiral of worsening disease and clinical outcomes manifest as cardio-renal syndromes. In addition to pharmacologic therapies (e.g., diuretics, beta adrenergic receptor blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and blood pressure control), special consideration should be given to behavioral modifications that avoid the pitfalls of polypharmacy and suboptimal renal and hepatic dosing, to which CCI patients may be particularly vulnerable. Smoking cessation, dietary modifications (e.g., early high-protein nutrition and late low-sodium diets), and increased physical activity are advised. Select patients benefit from cardiac re-synchronization therapy or renal replacement therapy. Coordinated, patient-centered care bundles may improve compliance with standards of care and patient outcomes. Given the complex, heterogeneous nature of cardiovascular and renal disease in CCI and the dismal long-term outcomes, further research is needed to clarify pathophysiologic mechanisms of cardio-renal syndromes in CCI and develop targeted therapies.
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Tseitkin B, Mårtensson J, Eastwood GM, Brown A, Ancona P, Lucchetta L, Iwashyna TJ, Robbins R, Bellomo R. Nature and impact of in-hospital complications associated with persistent critical illness. CRIT CARE RESUSC 2020; 22:378-387. [PMID: 38046870 PMCID: PMC10692497 DOI: 10.51893/2020.4.oa11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Persistent critical illness (PerCI) is defined as an intensive care unit (ICU) admission lasting ≥ 10 days. The in-hospital complications associated with its development are poorly understood. Aims: To test whether PerCI is associated with a greater prevalence, rate and specific types of in-hospital complications. Methods: Single-centre, retrospective, observational case-control study. Results: We studied 1200 patients admitted to a tertiary ICU from 2010 to 2015. Median ICU length of stay was 16 days (interquartile range [IQR], 12-23) for PerCI patients v 2.3 days (IQR, 1.1-3.7) for controls, and median hospital length of stay was 41 days (IQR, 22-75) v 8 days (IQR, 4-17) respectively. A greater proportion of PerCI patients received acute renal replacement therapy (37% v 6.8%) or underwent reintubation (17% v 1%) and/or tracheostomy (36% v 0.6%); P < 0.0001. Despite these complications, PerCI patients had similar hospital mortality (29% v 27%; P = 0.53). PerCI patients experienced a greater absolute number of complications (12.1 v 4.0 complications per patient; P < 0.0001) but had fewer exposure-adjusted complications (202 v 272 complications per 1000 hospital bed-days; P < 0.001) and a particularly high overall prevalence of specific complications. Conclusions: PerCI patients experience a higher prevalence, but not a higher rate, of exposure-adjusted complications. Some of these complications appear amenable to prevention, helping to define intervention targets in patients at risk of PerCI. Funding: Austin Hospital Intensive Care Trust Fund.
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Affiliation(s)
- Boris Tseitkin
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Johan Mårtensson
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Glenn M. Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Society Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Alastair Brown
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Paolo Ancona
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Intensive Care Medicine, Catholic University of the Sacred Heart, “A. Gemelli” University Hospital, Rome, Italy
| | - Luca Lucchetta
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Theodore J. Iwashyna
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Raymond Robbins
- Department of Administrative Informatics, Austin Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Society Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- School of Medicine, University of Melbourne, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital and University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, VIC, Australia
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Wintermann GB, Weidner K, Strauss B, Rosendahl J. Single assessment of delirium severity during postacute intensive care of chronically critically ill patients and its associated factors: post hoc analysis of a prospective cohort study in Germany. BMJ Open 2020; 10:e035733. [PMID: 33033083 PMCID: PMC7545620 DOI: 10.1136/bmjopen-2019-035733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES To assess the delirium severity (DS), its risk factors and association with adverse patient outcomes in chronically critically ill (CCI) patients. DESIGN A prospective cohort study. SETTING A tertiary care hospital with postacute intensive care units (ICUs) in Germany. PARTICIPANTS N=267 CCI patients with critical illness polyneuropathy and/or critical illness myopathy, aged 18-75 years, who had undergone elective tracheotomy for weaning failure. INTERVENTIONS None. MEASURES Primary outcomes: DS was assessed using the Confusion Assessment Method for the Intensive Care Unit-7 delirium severity score, within 4 weeks (t1) after the transfer to a tertiary care hospital. In post hoc analyses, univariate linear regressions were employed, examining the relationship of DS with clinical, sociodemographic and psychological variables. Secondary outcomes: additionally, correlations of DS with fatigue (using the Multidimensional Fatigue Inventory-20), quality of life (using the Euro-Quality of Life) and institutionalisation/mortality at 3 (t2) and 6 (t3) months follow-up were computed. RESULTS Of the N=267 patients analysed, 9.4% showed severe or most severe delirium symptoms. 4.1% had a full-syndromal delirium. DS was significantly associated with the severity of illness (p=0.016, 95% CI -0.1 to -0.3), number of medical comorbidities (p<0.001, 95% CI .1 to .3) and sepsis (p<0.001, 95% CI .3 to 1.0). Patients with a higher DS at postacute ICU (t1), showed a higher mental fatigue at t2 (p=0.008, 95% CI .13 to .37) and an increased risk for institutionalisation/mortality (p=0.043, 95% CI 1.1 to 28.9/p=0.015, 95% CI 1.5 to 43.2). CONCLUSIONS Illness severity is positively associated with DS during postacute care in CCI patients. An adequate management of delirium is essential in order to mitigate functional and cognitive long-term sequelae following ICU. TRIAL REGISTRATION NUMBER DRKS00003386.
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Affiliation(s)
- Gloria-Beatrice Wintermann
- Department of Psychotherapy and Psychosomatic Medicine, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Sachsen, Germany
| | - Kerstin Weidner
- Department of Psychotherapy and Psychosomatic Medicine, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Sachsen, Germany
| | - Bernhard Strauss
- Institute of Psychosocial Medicine, Psychotherapy and Psychooncology, Jena University Hospital, Jena, Thüringen, Germany
| | - Jenny Rosendahl
- Institute of Psychosocial Medicine, Psychotherapy and Psychooncology, Jena University Hospital, Jena, Thüringen, Germany
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Thüringen, Germany
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15
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Kohler J, Borchers F, Endres M, Weiss B, Spies C, Emmrich JV. Cognitive Deficits Following Intensive Care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:627-634. [PMID: 31617485 DOI: 10.3238/arztebl.2019.0627] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 02/06/2019] [Accepted: 07/16/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Illnesses that necessitate intensive care can impair cognitive function severely over the long term, leaving patients less able to cope with the demands of everyday living and markedly lowering their quality of life. There has not yet been any comprehensive study of the cognitive sequelae of critical illness among non- surgical patients treated in intensive care. The purpose of this review is to present the available study findings on cognitive deficits in such patients, with particular at- tention to prevalence, types of deficit, clinical course, risk factors, prevention, and treatment. METHODS This review is based on pertinent publications retrieved by a selective search in MEDLINE. RESULTS The literature search yielded 3360 hits, among which there were 14 studies that met our inclusion criteria. 17-78% of patients had cognitive deficits after dis- charge from the intensive care unit; most had never had a cognitive deficit before. Cognitive impairment often persisted for up to several years after discharge (0.5 to 9 years) and tended to improve over time. The only definite risk factor is delirium. CONCLUSION Cognitive dysfunction is a common sequela of the treatment of non-surgical patients in intensive care units. It is a serious problem for the affected persons and an increasingly important socio-economic problem as well. The effective management of delirium is very important. General conclusions are hard to draw from the available data because of heterogeneous study designs, varying methods of measurement, and differences among patient cohorts. Further studies are needed so that study designs and clinical testing procedures can be standard- ized and effective measures for prevention and treatment can be identified.
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Affiliation(s)
- Joel Kohler
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin; Department of Anesthesiology and Operative Intensive Care Medicine at Campus Benjamin Franklin Charité-Universitätsmedizin Berlin
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Haviland K, Tan KS, Schwenk N, Pillai MV, Stover DE, Downey RJ. Outcomes after long-term mechanical ventilation of cancer patients. BMC Palliat Care 2020; 19:42. [PMID: 32228554 PMCID: PMC7106688 DOI: 10.1186/s12904-020-00544-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 03/10/2020] [Indexed: 11/16/2022] Open
Abstract
Background The probability of weaning and of long-term survival of chronically mechanically ventilated cancer patients is unknown, with incomplete information available to guide therapeutic decisions. We sought to determine the probability of weaning and overall survival of cancer patients requiring long-term mechanical ventilation in a specialized weaning unit. Methods A single-institution retrospective review of patients requiring mechanical ventilation outside of a critical care setting from 2008 to 2012 and from January 1 to December 31, 2018, was performed. Demographic and clinical data were recorded, including cancer specifics, comorbidities, treatments, and outcomes. Overall survival was determined using the Kaplan-Meier approach. Time to weaning was analyzed using the cumulative incidence function, with death considered a competing risk. Prognostic factors were evaluated for use in prospective evaluations of weaning protocols. Results Between 2008 and 2012, 122 patients required mechanical ventilation outside of a critical care setting with weaning as a goal of care. The cumulative incidence of weaning after discharge from the intensive care unit was 42% at 21 days, 49% at 30 days, 58% at 60 days, 61% at 90 days, and 61% at 120 days. The median survival was 0.16 years (95% CI, 0.12 to 0.33) for those not weaned and 1.05 years (95% CI, 0.60 to 1.34) for those weaned. Overall survival at 1 year and 2 years was 52 and 32% among those weaned and 16 and 9% among those not weaned. During 2018, 36 patients at our institution required mechanical ventilation outside of a critical care setting, with weaning as a goal of care. Overall, with a median follow-up of 140 days (range, 0–425 days; average, 141 days), 25% of patients requiring long-term mechanical ventilation (9 of 36) are alive. Conclusions Cancer patients can be weaned from long-term mechanical ventilation, even after prolonged periods of support. Implementation of a resource-intensive weaning program did not improve rates of successful weaning. No clear time on mechanical ventilation could be identified beyond which weaning was unprecedented. Short-term overall survival for these patients is poor.
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Affiliation(s)
- Kelly Haviland
- Department of Nursing, Memorial Hospital, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nadja Schwenk
- Department of Nursing, Memorial Hospital, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Manju V Pillai
- Pulmonary Service, Department of Medicine, Memorial Hospital, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Diane E Stover
- Pulmonary Service, Department of Medicine, Memorial Hospital, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert J Downey
- Thoracic Service, Department of Surgery, Memorial Hospital, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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Risk Factors for Post-Traumatic Stress Disorder Symptoms in Surrogate Decision-Makers of Patients with Chronic Critical Illness. Ann Am Thorac Soc 2019; 15:1451-1458. [PMID: 30199658 DOI: 10.1513/annalsats.201806-420oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
RATIONALE Chronically critically ill patients are often dependent on family members for surrogate decision-making, and these surrogates are at high risk for emotional distress. We hypothesized that patient- and surrogate-specific risk factors for surrogate post-traumatic stress disorder (PTSD) symptoms can be identified early in the course of chronic critical illness. OBJECTIVES To identify risk factors for PTSD symptoms in surrogate decision-makers of chronically critically ill patients. METHODS We performed a secondary analysis of the database from a multicenter randomized trial of a communication intervention for chronic critical illness patients and surrogates. Variables preselected for plausible mechanism for increasing PTSD symptoms and identifiable by Day 10 of mechanical ventilation were included in the analysis for association with surrogate PTSD symptoms at 90 days, as measured by the Impact of Events Score-Revised (IES-R). Patient factors included demographics, insurance status, baseline functional status, chronic comorbidities, illness severity, and presence of advance directive. Surrogate variables included demographics, education level and employment, religion, relationship to patient, and Hospital Anxiety and Depression Scale score measured at enrollment. Multivariable linear regression models were then constructed for 26 potential risk factors, including biologically or mechanistically plausible confounders for each, with IES-R score as the outcome. All models were adjusted for multiple respondents, using a mixed model, considering the patients as a random factor. RESULTS Our analysis included 306 surrogates for 224 patients. A total of 49% of patients were female, and mean age was 59 years (95% confidence interval [CI], 56.4-60.7). A total of 71% of surrogates were female, and mean age was 51 years (95% CI, 49.3-52.4). After examining each potential risk factor in a separate multivariable model, only Day-10 surrogate Hospital Anxiety and Depression Scale score (β coefficient = 1.02; 95% CI, 0.73-1.30) and patient unresponsiveness (β coefficient = 8.39; 95% CI, 0.83-15.95) were associated with higher IES-R scores. CONCLUSIONS Among surrogate decision-makers for chronically critically ill patients, high anxiety and depression scores and patient unresponsiveness on or near Day 10 of mechanical ventilation are risk factors for PTSD symptoms at 90 days.
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Rafiq A, Ullah W, Naglak M, Schneider D. Characteristics and Outcomes of Patients with Partial Do Not Resuscitate Orders in a Large Community Hospital. Cureus 2019; 11:e6048. [PMID: 31819835 PMCID: PMC6886728 DOI: 10.7759/cureus.6048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Formal writing of do not resuscitate (DNR) orders first appeared in the literature in the late 20th century. Recently, providers have also noticed the presence of partial DNR orders while caring for patients. We sought to determine the effect of these orders on the clinical outcomes of the patients. Methods The study was a retrospective chart review covering a period of approximately 30 months. Patients included in the study were over 18 years of age and had a partial DNR order (i.e., chemical code, do not defibrillate (DND), do not intubate (DNI), intubate only, no cardiopulmonary resuscitation (CPR)) entered during hospitalization. Primary medical problems were categorized by organ system and the outcome was stated in terms of their disposition and mortality. Results A total of 71,143 code orders were entered during the study period, with partial DNR orders accounting for 1.8% of these orders (chemical code 2%, DND 0.8%, DNI 48%, intubate only 38%, and no CPR 10%). About 38% of all patients were discharged to home, 32% were discharged to a facility, and 11% were discharged on hospice. More than half of the patients did not have a palliative care consult. Of all the patients having partial code orders, about 150 patients had a rapid response team called on them and five patients had a cardiac arrest with a code blue activated on them. The mortality of these patients was significantly higher than other patients possibly due to confusing code orders. Surprisingly, a higher percentage of patients (19%) with a mean age significantly lower (p < 0.001) than discharged patients had inpatient mortality. Conclusion Our study demonstrates the first reported prevalence of partial DNR orders in the general inpatient population and its possible detrimental effects on the patient clinical course. This study offers several opportunities for quality improvement, such as developing prompts for the healthcare team to involve palliative care services more often for such patients.
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Affiliation(s)
- Ali Rafiq
- Internal Medicine, Abington Hospital, Jefferson Health, Abington, USA
| | - Waqas Ullah
- Internal Medicine, Abington Hospital, Jefferson Health, Abington, USA
| | - Mary Naglak
- Internal Medicine, Abington Hospital, Jefferson Health, Abington, USA
| | - Doron Schneider
- Internal Medicine, Abington Hospital, Jefferson Health, Abington, USA
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Jang CS, Wang JD. Predicting Mortality and Life Expectancy in Patients under Prolonged Mechanical Ventilation and Maintenance Dialysis. J Palliat Med 2019; 23:74-81. [PMID: 31347942 PMCID: PMC6931911 DOI: 10.1089/jpm.2018.0646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: The number of patients receiving prolonged mechanical ventilation (PMV) or maintenance dialysis (MD) is increasing worldwide. Identification of those with a short life expectancy is useful for early referral of palliative care. Objective: To determine the survival rate, life expectancy, and major prognostic factors in patients under both PMV and MD. Design: We extracted a 1:3.4 random sample of patients treated with mechanical ventilation (MV) from the National Health Insurance (NHI) Research Database of Taiwan from 2003 to 2007. Subjects who had undergone MD and received MV for longer than 21 days were enrolled. Setting/Subjects: There were 1035 patients who received both PMV and MD. Measurements: The survival rates and life expectancy were estimated. A multivariate proportional hazards model was constructed to validate the effects of different prognostic factors, including age, gender, hospital size, and major comorbidities. Results: The median length of survival of patients under both PMV and MD was 54 days. The three-month, six-month, and one-year survival rates were 40.8%, 24.1%, and 12.6%, respectively. The life expectancies of those older than 70 years were five months; those comorbid with cancer and septicemia were 112 and 90 days, respectively. After adjustments for covariates, we found following prognostic factors were statistically significant: gangrene, peritonitis, liver cirrhosis, cancer, septicemia, hydrocephalus, having device complications, and shock. Conclusions: More than 85% of patients receiving both PMV and MD died within one year. Communication and early referral for palliative care would be indicated for those comorbid with significant prognostic factors.
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Affiliation(s)
- Chang-Sheng Jang
- Puli Christian Hospital, Nantou County, Taiwan.,Department of Public Health, National Cheng Kung University College of Medicine, Tainan, Taiwan
| | - Jung-Der Wang
- Department of Public Health, National Cheng Kung University College of Medicine, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.,Department of Occupational and Environmental Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
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20
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EL PACIENTE CRÍTICO CRÓNICO. REVISTA MÉDICA CLÍNICA LAS CONDES 2019. [DOI: 10.1016/j.rmclc.2019.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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21
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Wendlandt B, Ceppe A, Choudhury S, Cox CE, Hanson LC, Danis M, Tulsky JA, Nelson JE, Carson SS. Modifiable elements of ICU supportive care and communication are associated with surrogates' PTSD symptoms. Intensive Care Med 2019; 45:619-626. [PMID: 30790028 DOI: 10.1007/s00134-019-05550-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 01/28/2019] [Indexed: 01/16/2023]
Abstract
PURPOSE To identify specific components of ICU clinician supportive care and communication that are associated with increased post-traumatic stress disorder (PTSD) symptoms for surrogate decision makers of patients with chronic critical illness (CCI). METHODS We conducted a secondary analysis of data from a randomized controlled trial of palliative care-led meetings to provide information and support for CCI surrogates. The primary outcome for this secondary analysis was PTSD symptoms at 90 days, measured by the Impact of Event Scale-Revised (IES-R). Caregiver perceptions of clinician support and communication were assessed using a version of the After-Death Bereaved Family Member Interview (ADBFMI) instrument modified for use in non-bereaved in addition to bereaved caregivers. The association between ADBFMI items and IES-R score was analyzed using multiple linear regression. RESULTS Ninety-day follow up was complete for 306 surrogates corresponding to 224 patients. Seventy-one percent of surrogates were female, and the mean age was 51 years. Of the domains, negative perception of the patient's physical comfort and emotional support was associated with the greatest increase in surrogate PTSD symptoms (beta coefficient 1.74, 95% CI 0.82-2.65). The three specific preselected items associated with increased surrogate PTSD symptoms were surrogate perception that clinicians did not listen to concerns (beta coefficient 10.7, 95% CI 3.6-17.9), failure of the physician to explain how the patient's pain would be treated (beta coefficient 12.1, 95% CI 4.9-19.3), and lack of sufficient religious contact (beta coefficient 11.7, 95% CI 2-21.3). CONCLUSION Modifiable deficits in ICU clinician support and communication were associated with increased PTSD symptoms among CCI surrogates.
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Affiliation(s)
- Blair Wendlandt
- University of North Carolina School of Medicine, 130 Mason Farm Road CB#7020, Chapel Hill, NC, 27599, USA.
| | - Agathe Ceppe
- University of North Carolina School of Medicine, 130 Mason Farm Road CB#7020, Chapel Hill, NC, 27599, USA
| | - Summer Choudhury
- University of North Carolina School of Medicine, 130 Mason Farm Road CB#7020, Chapel Hill, NC, 27599, USA
| | | | - Laura C Hanson
- University of North Carolina School of Medicine, 130 Mason Farm Road CB#7020, Chapel Hill, NC, 27599, USA
| | - Marion Danis
- National Institutes of Health, Bethesda, MD, USA
| | - James A Tulsky
- Dana Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Judith E Nelson
- Memorial Sloan Kettering Cancer Center and Weill-Cornell Medical College, New York, NY, USA
| | - Shannon S Carson
- University of North Carolina School of Medicine, 130 Mason Farm Road CB#7020, Chapel Hill, NC, 27599, USA
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Iwashyna TJ, Viglianti EM. Patient and Population-Level Approaches to Persistent Critical Illness and Prolonged Intensive Care Unit Stays. Crit Care Clin 2018; 34:493-500. [PMID: 30223989 PMCID: PMC6146412 DOI: 10.1016/j.ccc.2018.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The differential diagnosis of prolonged intensive care unit (ICU) stays includes intrinsic patient and admitting diagnostic characteristics, occurrences during the course of critical illness, and system failures. Existing data suggest that the most common cause of prolonged ICU stay is the development of new cascading problems, which is now more related to ongoing critical illness than the original reason for ICU admission. Accepting the dynamism inherent in such a clinical course has implications for contemporary clinical care.
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Affiliation(s)
- Theodore J Iwashyna
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Veterans Affairs Center for Clinical Management Research, HSR&D Center for Excellence, Ann Arbor, MI
- Institute for Social Research, Ann Arbor, Michigan
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McCluskey GE, Yates P, Villemagne VL, Rowe C, Szoeke CEI. Self-reported confusion is related to global and regional β-amyloid: data from the Women's healthy ageing project. Brain Imaging Behav 2018; 12:78-86. [PMID: 28108945 DOI: 10.1007/s11682-016-9668-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Disease-modifying treatments for Alzheimer's disease (AD) may require implementation during early stages of β-amyloid accumulation, well before patients have objective cognitive decline. In this study we aimed to assess the clinical value of subjective cognitive impairment (SCI) by examining the cross-sectional relationship between β-amyloid load and SCI. Cerebral β-amyloid and SCI was assessed in a cohort of 112 cognitively normal subjects. Subjective cognition was evaluated using specific questions on memory and cognition and the MAC-Q. Participants had cerebral β-amyloid load measured with 18F-Florbetaben Positron Emission Tomography (PET). No associations were found between measures of subjective memory impairment and cerebral β-amyloid. However, by self-reported confusion was predictive of a higher global β-amyloid burden (p = 0.002), after controlling for confounders. Regional analysis revealed significant associations of confusion with β-amyloid in the prefrontal region (p = 0.004), posterior cingulate and precuneus cortices (p = 0.004) and the lateral temporal lobes (p = 0.001) after controlling for confounders. An in vivo biomarker for AD pathology was associated with SCI by self-reported confusion on cross-sectional analysis. Whilst there has been a large body of research on SMC, our results indicate more research is needed to explore symptoms of confusion.
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Affiliation(s)
- Georgia E McCluskey
- Centre for Medical Research, Royal Melbourne Hospital, Parkville, VIC, 3050, Australia.,Department of Medicine, University of Melbourne, Parkville, VIC, 3050, Australia
| | - Paul Yates
- Department of Nuclear Medicine and Centre for PET, Austin Health, Heidelberg, VIC, 3084, Australia
| | - Victor L Villemagne
- Department of Nuclear Medicine and Centre for PET, Austin Health, Heidelberg, VIC, 3084, Australia
| | - Christopher Rowe
- Department of Nuclear Medicine and Centre for PET, Austin Health, Heidelberg, VIC, 3084, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, 3050, Australia
| | - Cassandra E I Szoeke
- Centre for Medical Research, Royal Melbourne Hospital, Parkville, VIC, 3050, Australia. .,Department of Medicine, University of Melbourne, Parkville, VIC, 3050, Australia. .,Institute for Health and Ageing, Melbourne, 3000, Australia.
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Liu X, Yu Y, Zhu S. Inflammatory markers in postoperative delirium (POD) and cognitive dysfunction (POCD): A meta-analysis of observational studies. PLoS One 2018; 13:e0195659. [PMID: 29641605 PMCID: PMC5895053 DOI: 10.1371/journal.pone.0195659] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 03/27/2018] [Indexed: 11/19/2022] Open
Abstract
Background The aim of this study was to summarize and discuss the similarities and differences in inflammatory biomarkers in postoperative delirium (POD) and cognitive dysfunction (POCD). Methods A systematic retrieval of literature up to June 2017 in PubMed, Embase, the Cochrane Library, the China National Knowledge Infrastructure database, and the Wanfang database was conducted. Extracted data were analyzed with STATA (version 14). The standardized mean difference (SMD) and the 95% confidence interval (95% CI) of each indicator were calculated using a random effect model. We also performed tests of heterogeneity, sensitivity analysis, assessments of bias, and meta-regression in this meta-analysis. Results A total of 54 observational studies were included. By meta-analysis we found significantly increased C-reactive protein (CRP) (9 studies, SMD 0.883, 95% CI 0.130 to 1.637, P = 0.022 in POD; 10 studies, SMD -0.133, 95% CI -0.512 to 0.246, P = 0.429 in POCD) and interleukin (IL)-6 (7 studies, SMD 0.386, 95% CI 0.054 to 0.717, P = 0.022 in POD; 16 studies, SMD 0.089, 95% CI -0.133 to 0.311, P = 0.433 in POCD) concentrations in both POD and POCD patients. We also found that the SMDs of CRP and IL-6 from POCD patients were positively correlated with surgery type in the meta-regression (CRP: Coefficient = 1.555365, P = 0.001, 10 studies; IL-6: Coefficient = -0.6455521, P = 0.086, 16 studies). Conclusion Available evidence from medium-to-high quality observational studies suggests that POD and POCD are indeed correlated with the concentration of peripheral and cerebrospinal fluid (CSF) inflammatory markers. Some of these markers, such as CRP and IL-6, play roles in both POD and POCD, while others are specific to either one of them.
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Affiliation(s)
- Xuling Liu
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Yang Yu
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Shengmei Zhu
- Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
- * E-mail:
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Torbic H, Duggal A. Antipsychotics, Delirium, and Acute Respiratory Distress Syndrome: What Is the Link? Pharmacotherapy 2018; 38:462-469. [PMID: 29444340 DOI: 10.1002/phar.2093] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is an acute inflammatory process that impairs the ability of the lungs to oxygenate and ultimately leads to respiratory failure. Patients who develop ARDS often have prolonged and complicated hospital courses putting them at risk for intensive care unit (ICU) delirium. Patients with ICU delirium often need chemical sedation, mechanical ventilation, prolonged duration of ICU and hospital stays, and they experience long-term cognitive impairment and increased mortality. In a patient with ARDS, ICU delirium further complicates the hospital course and increases the risk of morbidity and mortality. Antipsychotics are prescribed to decrease the severity and duration of ICU delirium, thus potentially decreasing their risk of morbidity and mortality. However, antipsychotics are associated with many adverse effects including respiratory failure. Given the long-term sequelae associated with the development of ICU delirium and the risks associated with antipsychotic use, clinicians must weigh the risks and benefits of antipsychotic use. This review investigates the interrelationship between ARDS, delirium, and antipsychotic use. In addition to discussing relevant studies evaluating antipsychotics for the prevention and treatment of delirium, we investigate safety concerns with the use of antipsychotics, especially as they relate to ARDS. Using the data compiled in this review, clinicians can make an informed decision about the use of antipsychotics for the prevention or treatment of delirium, with special consideration for their patients with ARDS. Future studies are needed to critically evaluate antipsychotic timing, dose, and duration for the prevention and treatment of ICU delirium and specifically evaluate the impact in special populations, particularly patients with ARDS.
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Affiliation(s)
- Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
| | - Abhijit Duggal
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
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26
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Loss SH, Nunes DSL, Franzosi OS, Salazar GS, Teixeira C, Vieira SRR. Chronic critical illness: are we saving patients or creating victims? Rev Bras Ter Intensiva 2018; 29:87-95. [PMID: 28444077 PMCID: PMC5385990 DOI: 10.5935/0103-507x.20170013] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 09/05/2016] [Indexed: 12/15/2022] Open
Abstract
The technological advancements that allow support for organ dysfunction have led
to an increase in survival rates for the most critically ill patients. Some of
these patients survive the initial acute critical condition but continue to
suffer from organ dysfunction and remain in an inflammatory state for long
periods of time. This group of critically ill patients has been described since
the 1980s and has had different diagnostic criteria over the years. These
patients are known to have lengthy hospital stays, undergo significant
alterations in muscle and bone metabolism, show immunodeficiency, consume
substantial health resources, have reduced functional and cognitive capacity
after discharge, create a sizable workload for caregivers, and present high
long-term mortality rates. The aim of this review is to report on the most
current evidence in terms of the definition, pathophysiology, clinical
manifestations, treatment, and prognosis of persistent critical illness.
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Affiliation(s)
- Sergio Henrique Loss
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil
| | - Diego Silva Leite Nunes
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Oellen Stuani Franzosi
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Departamento de Nutrição, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil
| | | | - Cassiano Teixeira
- Faculdade de Medicina, Universidade Federal de Ciências da Saúde de Porto Alegre - Porto Alegre (RS), Brasil
| | - Silvia Regina Rios Vieira
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil.,Departamento de Clínica Médica, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
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Abstract
Many older adults in the United States receive invasive medical care near the end of life, often in an intensive care unit (ICU). However, most older adults report preferences to avoid this type of medical care and to prioritize comfort and quality of life near death. We propose a novel term, "clinical momentum," to describe a system-level, latent, previously unrecognized property of clinical care that may contribute to the provision of unwanted care in the ICU. The example of chronic critical illness illustrates how clinical momentum is generated and propagated during the care of patients with prolonged illness. The ICU is an environment that is generally permissive of intervention, and clinical practice norms and patterns of usual care can promote the accumulation of multiple interventions over time. Existing models of medical decision-making in the ICU describe how individual signs, symptoms, or diagnoses automatically lead to intervention, bypassing opportunities to deliberate about the value of an intervention in the context of a patient's likely outcome or treatment preferences. We hypothesize that clinical momentum influences patients, families, and physicians to accept or tolerate ongoing interventions without consideration of likely outcomes, eventually leading to the delivery of unwanted care near the end of life. In the future, a mixed-methods research program could refine the conceptual model of clinical momentum, measure its impact on clinical practice, and interrupt its influence on unwanted care near the end of life.
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Rosenthal MD, Kamel AY, Rosenthal CM, Brakenridge S, Croft CA, Moore FA. Chronic Critical Illness: Application of What We Know. Nutr Clin Pract 2018; 33:39-45. [PMID: 29323761 DOI: 10.1002/ncp.10024] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/08/2017] [Indexed: 12/16/2022] Open
Abstract
Over the last decade, chronic critical illness (CCI) has emerged as an epidemic in intensive care unit (ICU) survivors worldwide. Advances in ICU technology and implementation of evidence-based care bundles have significantly decreased early deaths and have allowed patients to survive previously lethal multiple organ failure (MOF). Many MOF survivors, however, experience a persistent dysregulated immune response that is causing an increasingly predominant clinical phenotype called the persistent inflammation, immunosuppression, and catabolism syndrome (PICS). The elderly are especially vulnerable; thus, as the population ages the prevalence of this CCI/PICS clinical trajectory will undoubtedly grow. Unfortunately, there are no proven therapies to prevent PICS, and multimodality interventions will be required. The purpose of this review is to: (1) discuss CCI as it relates to PICS, (2) identify the burden on healthcare and poor outcomes of these patients, and (3) describe possible nutrition interventions for the CCI/PICS phenotype.
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Affiliation(s)
- Martin D Rosenthal
- Department of Surgery, Division of Acute Care Surgery and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Amir Y Kamel
- Department of Pharmacy, UF Health, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | | | - Scott Brakenridge
- Department of Surgery, Division of Acute Care Surgery and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Chasen A Croft
- Department of Surgery, Division of Acute Care Surgery and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Frederick A Moore
- Department of Surgery, Division of Acute Care Surgery and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, Florida, USA
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30
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Abstract
Determining effective decision support strategies that enhance quality of end-of-life decision making in the intensive care unit is a research priority. This systematic review identified interventional studies describing the effectiveness of decision support interventions administered to critically ill patients or their surrogate decision makers. We conducted a systematic literature search using PubMed, CINAHL, and Cochrane. Our search returned 121 articles, 22 of which met the inclusion criteria. The search generated studies with significant heterogeneity in the types of interventions evaluated and varied patient and surrogate decision-maker outcomes, which limited the comparability of the studies. Few studies demonstrated significant improvements in the primary outcomes. In conclusion, there is limited evidence on the effectiveness of end-of-life decision support for critically ill patients and their surrogate decision makers. Additional research is needed to develop and evaluate innovative decision support interventions for end-of-life decision making in the intensive care unit.
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31
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Nelson JE, Hanson LC, Keller KL, Carson SS, Cox CE, Tulsky JA, White DB, Chai EJ, Weiss SP, Danis M. The Voice of Surrogate Decision-Makers. Family Responses to Prognostic Information in Chronic Critical Illness. Am J Respir Crit Care Med 2017; 196:864-872. [PMID: 28387538 DOI: 10.1164/rccm.201701-0201oc] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
RATIONALE Information from clinicians about the expected course of the patient's illness is relevant and important for decision-making by surrogates for chronically critically ill patients on mechanical ventilation. OBJECTIVES To observe how surrogates of chronically critically ill patients respond to information about prognosis from palliative care clinicians. METHODS This was a qualitative analysis of a consecutive sample of audio-recorded meetings from a larger, multisite, randomized trial of structured informational and supportive meetings led by a palliative care physician and nurse practitioner for surrogates of patients in medical intensive care units with chronic critical illness (i.e., adults mechanically ventilated for ≥7 days and expected to remain ventilated and survive for ≥72 h). MEASUREMENTS AND MAIN RESULTS A total of 66 audio-recorded meetings involving 51 intervention group surrogates for 43 patients were analyzed using grounded theory. Six main categories of surrogate responses to prognostic information were identified: (1) receptivity, (2) deflection/rejection, (3) emotion, (4) characterization of patient, (5) consideration of surrogate role, and (6) mobilization of support. Surrogates responded in multiple and even antithetical ways, within and across meetings. CONCLUSIONS Prognostic disclosure by skilled clinician communicators evokes a repertoire of responses from surrogates for the chronically critically ill. Recognition of these response patterns may help all clinicians better communicate their support to patients and families facing chronic critical illness and inform interventions to support surrogate decision-makers in intensive care units. Clinical trial registered with www.clinicaltrials.gov (NCT 01230099).
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Affiliation(s)
- Judith E Nelson
- 1 Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York
| | - Laura C Hanson
- 2 University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | - Shannon S Carson
- 2 University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | - James A Tulsky
- 5 Dana Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Douglas B White
- 6 University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Emily J Chai
- 3 Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Marion Danis
- 7 National Institutes of Health, Bethesda, Maryland
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Aslakson RA, Schuster ALR, Lynch TJ, Weiss MJ, Gregg L, Miller J, Isenberg SR, Crossnohere NL, Conca-Cheng AM, Volandes AE, Smith TJ, Bridges JFP. Developing the Storyline for an Advance Care Planning Video for Surgery Patients: Patient-Centered Outcomes Research Engagement from Stakeholder Summit to State Fair. J Palliat Med 2017; 21:89-94. [PMID: 28817359 DOI: 10.1089/jpm.2017.0106] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Patient-centered outcomes research (PCOR) methods and social learning theory (SLT) require intensive interaction between researchers and stakeholders. Advance care planning (ACP) is valuable before major surgery, but a systematic review found no extant perioperative ACP tools. Consequently, PCOR methods and SLT can inform the development of an ACP educational video for patients and families preparing for major surgery. OBJECTIVE The objective is to develop and test acceptability of an ACP video storyline. DESIGN The design is a stakeholder-guided development of the ACP video storyline. Design-thinking methods explored and prioritized stakeholder perspectives. Patients and family members evaluated storyboards containing the proposed storyline. SETTING/SUBJECTS The study was conducted at hospital outpatient surgical clinics, in-person stakeholder summit, and the 2014 Maryland State Fair. MEASUREMENTS Measurements are done through stakeholder engagement and deidentified survey. RESULTS Stakeholders evaluated and prioritized evidence from an environmental scan. A surgeon, family member, and palliative care physician team iteratively developed a script featuring 12 core themes and worked with a medical graphic designer to translate the script into storyboards. For 10 days, 359 attendees of the 2014 Maryland State Fair evaluated the storyboards and 87% noted that they would be "very comfortable" or "comfortable" seeing the storyboard before major surgery, 89% considered the storyboards "very helpful" or "helpful," and 89% would "definitely recommend" or "recommend" this story to others preparing for major surgery. CONCLUSIONS Through an iterative process utilizing diverse PCOR engagement methods and informed by SLT, storyboards were developed for an ACP video. Field testing revealed the storyline to be highly meaningful for surgery patients and family members.
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Affiliation(s)
- Rebecca A Aslakson
- 1 Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine , Baltimore, Maryland.,2 Armstrong Institute for Patient Safety and Quality, The Johns Hopkins School of Medicine , Baltimore, Maryland.,3 Palliative Care Program, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins , Baltimore, Maryland
| | - Anne L R Schuster
- 4 Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Thomas J Lynch
- 1 Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine , Baltimore, Maryland
| | - Matthew J Weiss
- 5 Department of Surgery, The Johns Hopkins School of Medicine , Baltimore, Maryland
| | - Lydia Gregg
- 6 Division of Interventional Neuroradiology, Department of Art as Applied to Medicine, The Johns Hopkins School of Medicine , Baltimore, Maryland
| | - Judith Miller
- 7 Patient-Family Member Research Partner , Ellicott City, Maryland
| | - Sarina R Isenberg
- 8 Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Norah L Crossnohere
- 8 Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Alison M Conca-Cheng
- 1 Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine , Baltimore, Maryland
| | - Angelo E Volandes
- 9 Department of Medicine, Massachusetts General Hospital , Boston, Massachusetts
| | - Thomas J Smith
- 3 Palliative Care Program, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins , Baltimore, Maryland
| | - John F P Bridges
- 3 Palliative Care Program, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins , Baltimore, Maryland
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Neumeier A, Nordon-Craft A, Malone D, Schenkman M, Clark B, Moss M. Prolonged acute care and post-acute care admission and recovery of physical function in survivors of acute respiratory failure: a secondary analysis of a randomized controlled trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:190. [PMID: 28732512 PMCID: PMC5521116 DOI: 10.1186/s13054-017-1791-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 07/07/2017] [Indexed: 11/25/2022]
Abstract
Background The proportion of survivors of acute respiratory failure is growing; yet, many do not regain full function and require prolonged admission in an acute or post-acute care facility. Little is known about their trajectory of functional recovery. We sought to determine whether prolonged admission influenced the trajectory of physical function recovery and whether patient age modified the recuperation rate. Methods We performed a secondary analysis of a randomized clinical trial of intensive physical therapy for patients with acute respiratory failure requiring mechanical ventilation for ≥4 days. The primary outcome was Continuous Scale Physical Functional Performance, short form (CS-PFP-10), score. Predictor variables included prolonged admission in an acute or post-acute care facility at 1 month, time, and patient age. To determine whether the association between admission and functional outcome varied over time, a multivariable mixed effects linear regression model was fit using an interaction between prolonged admission and time with a primary outcome of total CS-PFP-10 score. Results Of the 89 patients included, 56% (50 of 89) required prolonged admission. At 1 month, patients who remained admitted had CS-PFP-10 scores that were 20.1 (CI 10.4–29.8) points lower (p < 0.0001) than patients who were discharged to home. However, there was no difference in the rate at which physical function improved from 3 to 6 months for patients who required prolonged admission compared with those who returned home (p = 0.24 for interaction between prolonged admission and time). Adjusted for age, Acute Physiology and Chronic Health Evaluation II score, and sex, both groups had CS-PFP-10 scores that were 8.2 (CI 4.5–12.0) points higher at 6 months than at 3 months (p < 0.0001). For each additional year in patient age, CS-PFP-10 recovered 0.36 points slower (95% CI 0.12–0.61; p = 0.004). Conclusions Patients who require prolonged admission after acute respiratory failure have significantly lower physical functional performance than patients who return home. However, the rates of physical functional recovery between the two groups do not differ. The majority of survivors do not recover sufficiently to achieve functional independence by 6 months. Older age negatively influences the trajectory of functional recovery. Trial registration ClinicalTrials.gov, NCT01058421. Registered on 26 January 2010. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1791-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna Neumeier
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Research 2, Box C272, 12700 East 19th Avenue, Aurora, CO, 80045, USA.
| | - Amy Nordon-Craft
- Physical Therapy Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Dan Malone
- Physical Therapy Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Margaret Schenkman
- Physical Therapy Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Brendan Clark
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Research 2, Box C272, 12700 East 19th Avenue, Aurora, CO, 80045, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Research 2, Box C272, 12700 East 19th Avenue, Aurora, CO, 80045, USA
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Prognostic Factors for Long-Term Mortality in Critically Ill Patients Treated With Prolonged Mechanical Ventilation: A Systematic Review. Crit Care Med 2017; 45:69-74. [PMID: 27618272 DOI: 10.1097/ccm.0000000000002022] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Long-term survival for patients treated with prolonged mechanical ventilation is generally poor; however, patient-level factors associated with long-term mortality are unclear. Our objective was to systematically review the biomedical literature and synthesize data for prognostic factors that predict long-term mortality in prolonged mechanical ventilation patients. DATA SOURCES We searched PubMed, CINAHL, and Cochrane Library from 1988 to 2015 for studies on prolonged mechanical ventilation utilizing a comprehensive strategy without language restriction. STUDY SELECTION We included studies of adults 1) receiving mechanical ventilation for more than or equal to 14 days, 2) admitted to a ventilator weaning unit, or 3) received a tracheostomy for acute respiratory failure. We analyzed articles that used a multivariate analysis to identify patient-level factors associated with long-term mortality (≥ 6 mo from when the patient met criteria for receiving prolonged mechanical ventilation). DATA EXTRACTION We used a standardized data collection tool and assessed study quality with a customized Newcastle-Ottawa Scale. We abstracted the strength of association between each prognostic factor and long-term mortality. Individual prognostic factors were then designated as strong, moderate, weak, or inconclusive based on an a priori previously published schema. DATA SYNTHESIS A total of 7,411 articles underwent relevance screening; 419 underwent full article review. We identified 14 articles that contained a multivariate analysis. We abstracted 19 patient-level factors that showed association with long-term mortality. Six factors demonstrated strong strength of evidence for association with the primary outcome: age, vasopressor requirement, thrombocytopenia, preexisting kidney disease, failed ventilator liberation, and acute kidney injury ± hemodialysis requirement. All factors, except preexisting kidney disease and failed ventilator liberation, were measured at the time the patients met criteria for prolonged mechanical ventilation. CONCLUSIONS Despite the magnitude of the public health challenge posed by the prolonged mechanical ventilation population, only 14 articles in the biomedical literature have tested patient-level factors associated with long-term mortality. Further research is needed to inform optimal patient selection for prolonged mechanical ventilation.
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Pollack LR, Goldstein NE, Gonzalez WC, Blinderman CD, Maurer MS, Lederer DJ, Baldwin MR. The Frailty Phenotype and Palliative Care Needs of Older Survivors of Critical Illness. J Am Geriatr Soc 2017; 65:1168-1175. [PMID: 28263377 DOI: 10.1111/jgs.14799] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To assess symptoms in older intensive care unit (ICU) survivors and determine whether post-ICU frailty identifies those with the greatest palliative care needs. DESIGN A prospective cohort study. SETTING Urban tertiary care hospital and community hospital. PARTICIPANTS Medical ICU survivors of mechanical ventilation aged 65 and older (N = 125). MEASUREMENTS Baseline measurements of the Edmonton Symptom Assessment Scale (ESAS), categorized as mild (0-3), moderate (4-6), and severe (7-10), and the frailty phenotype were made during the week before hospital discharge. Functional recovery was defined as a return to a Katz activity of daily living dependency count less than or equal to the prehospitalization dependency count within 3 months. In the last 29 participants recruited, we made additional assessments of fatigue and ESAS both at baseline and 1 month after discharge. RESULTS Fatigue was the most-prevalent moderate to severe symptom (74%), followed by dyspnea (53%), drowsiness (50%), poor appetite (47%), pain (45%), depression (42%), anxiety (36%), and nausea (17%). At 1-month follow-up, there were no significant differences in the proportions of participants with moderate to severe symptoms. Each increase in baseline ESAS fatigue severity category was associated with 55% lower odds of functional recovery (odds ratio = 0.45, 95% confidence interval = 0.24-0.84), independent of age, sex, comorbidities, and critical illness severity. Frail participants had a higher median baseline total ESAS symptom distress score (34, interquartile range (IQR) 23-44) than nonfrail participants (13, IQR 9-22) (P < .001). CONCLUSION Older ICU survivors have a high burden of palliative care needs that persist 1 month after discharge. Fatigue is the most-prevalent symptom and may interfere with recovery. Post-ICU frailty may be a useful trigger for palliative care consultation and a treatment target.
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Affiliation(s)
- Lauren R Pollack
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York
| | - Nathan E Goldstein
- Mount Sinai Beth Israel, Division of Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Wendy C Gonzalez
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York
| | - Craig D Blinderman
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York
| | - Mathew S Maurer
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York
| | - David J Lederer
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Matthew R Baldwin
- Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, New York.,Columbia Aging Center, Mailman School of Public Health, Columbia University, New York, New York
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DeForest A, Blinderman CD. Persistent Delirium in Chronic Critical Illness as a Prodrome Syndrome before Death. J Palliat Med 2017; 20:569-572. [PMID: 28437207 DOI: 10.1089/jpm.2016.0415] [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: 01/29/2023] Open
Abstract
BACKGROUND Chronic critical illness (CCI) patients have poor functional outcomes, high risk of mortality, and significant sequelae, including delirium and cognitive dysfunction. The prognostic significance of persistent delirium in patients with CCI has not been well described. OBJECTIVE We report a case of a patient with CCI following major cardiac surgery who was hemodynamically stable following a long course in the cardiothoracic intensive care unit (CTICU), but had persistent and unremitting delirium. Despite both pharmacological and nonpharmacological approaches to improve his delirium, the patient ultimately continued to have symptoms of delirium and subsequently died in the CTICU. Efforts to reconsider the goals of care, given his family's understanding of his values, were met with resistance as his cardiothoracic surgeon believed that he had a reasonable chance of recovery since his organs were not in failure. This case description raises the question of whether we should consider persistent delirium as a prodrome syndrome before death in patients with CCI. DESIGN Study and analysis of a case of a patient with CCI following major cardiothoracic surgery who was hemodynamically stable with persistent delirium. CONCLUSIONS Further studies of the prevalence and outcomes of prolonged or persistent agitated delirium in patients with chronic critical illness are needed to provide prognostic information that can assist patients and families in receiving care that accords with their goals and values.
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Affiliation(s)
- Anna DeForest
- 1 College of Physicians and Surgeons, Columbia University , New York, New York
| | - Craig D Blinderman
- 2 Adult Palliative Care Service, Columbia University Medical Center and NewYork-Presbyterian Hospital , New York, New York
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37
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Cortese GP, Burger C. Neuroinflammatory challenges compromise neuronal function in the aging brain: Postoperative cognitive delirium and Alzheimer's disease. Behav Brain Res 2016; 322:269-279. [PMID: 27544872 DOI: 10.1016/j.bbr.2016.08.027] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 08/08/2016] [Accepted: 08/11/2016] [Indexed: 12/19/2022]
Abstract
Alzheimer's disease (AD) is a progressive neurodegenerative disease that targets memory and cognition, and is the most common form of dementia among the elderly. Although AD itself has been extensively studied, very little is known about early-stage preclinical events and/or mechanisms that may underlie AD pathogenesis. Since the majority of AD cases are sporadic in nature, advancing age remains the greatest known risk factor for AD. However, additional environmental and epigenetic factors are thought to accompany increasing age to play a significant role in the pathogenesis of AD. Postoperative cognitive delirium (POD) is a behavioral syndrome that primarily occurs in elderly patients following a surgical procedure or injury and is characterized by disruptions in cognition. Individuals that experience POD are at an increased risk for developing dementia and AD compared to normal aging individuals. One way in which cognitive function is affected in cases of POD is through activation of the inflammatory cascade following surgery or injury. There is compelling evidence that immune challenges (surgery and/or injury) associated with POD trigger the release of pro-inflammatory cytokines into both the periphery and central nervous system. Thus, it is possible that cognitive impairments following an inflammatory episode may lead to more severe forms of dementia and AD pathogenesis. Here we will discuss the inflammation associated with POD, and highlight the advantages of using POD as a model to study inflammation-evoked cognitive impairment. We will explore the possibility that advancing age and immune challenges may provide mechanistic evidence correlating early life POD with AD. We will review and propose neural mechanisms by which cognitive impairments occur in cases of POD, and discuss how POD may augment the onset of AD.
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Affiliation(s)
- Giuseppe P Cortese
- Department of Neurology, University of Wisconsin-Madison, Medical Sciences Center, 1300 University Ave, Room 73 Bardeen Madison, WI 53706, USA.
| | - Corinna Burger
- Department of Neurology, University of Wisconsin-Madison, Medical Sciences Center, 1300 University Ave, Room 73 Bardeen Madison, WI 53706, USA
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Abstract
The term “dementia” describes various neurodegenerative disorders that effect cognition, including Alzheimer disease, vascular dementia, and others. This article reviews the diagnosis and management of common types of dementia and comorbidities. Dementias are differentiated clinically by history, symptom presentation, and exclusion of other causes through laboratory and imaging studies. Cholinesterase inhibitors are useful but may not be effective for all types of dementia and provide only modest benefits. Certain medical comorbidities may increase the risk of dementia, although genetics are also important in its etiology. Psychiatric comorbidities in dementia include delirium, which is treated primarily by addressing underlying medical disorders, but antipsychotics can be useful for symptom management and patient comfort. Nonpharmacologic interventions are first-line treatments for other psychiatric comorbidities, although drug therapy may be useful in some cases. The management of patients with dementia presents many challenges and will continue to do so unless agents with pronounced disease-modifying capabilities are developed.
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Affiliation(s)
- Keith A. Swanson
- The University of Oklahoma College of Pharmacy, Department of Pharmacy: Clinical and Administrative Sciences, Oklahoma City, Oklahoma
| | - Ryan M. Carnahan
- The University of Oklahoma College of Pharmacy, Department of Pharmacy: Clinical and Administrative Sciences, Tulsa, Oklahoma,
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Sakusic A, Gajic O. Chronic critical illness: unintended consequence of intensive care medicine. THE LANCET RESPIRATORY MEDICINE 2016; 4:531-532. [PMID: 27155771 DOI: 10.1016/s2213-2600(16)30066-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 04/13/2016] [Indexed: 12/31/2022]
Affiliation(s)
- Amra Sakusic
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA; Department of Internal Medicine and Department of Pulmonary Medicine, Tuzla University Medical Center, Tuzla, Bosnia and Herzegovina
| | - Ognjen Gajic
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA; Department of Medicine, Multidisciplinary Epidemiology and Translational Research in Intensive Care, Emergency and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
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Development and Validation of a Mortality Prediction Model for Patients Receiving 14 Days of Mechanical Ventilation. Crit Care Med 2016; 43:2339-45. [PMID: 26247337 DOI: 10.1097/ccm.0000000000001205] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The existing risk prediction model for patients requiring prolonged mechanical ventilation is not applicable until after 21 days of mechanical ventilation. We sought to develop and validate a mortality prediction model for patients earlier in the ICU course using data from day 14 of mechanical ventilation. DESIGN Multicenter retrospective cohort study. SETTING Forty medical centers across the United States. PATIENTS Adult patients receiving at least 14 days of mechanical ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Predictor variables were measured on day 14 of mechanical ventilation in the development cohort and included in a logistic regression model with 1-year mortality as the outcome. Variables were sequentially eliminated to develop the ProVent 14 model. This model was then generated in the validation cohort. A simplified prognostic scoring rule (ProVent 14 Score) using categorical variables was created in the development cohort and then tested in the validation cohort. Model discrimination was assessed by the area under the receiver operator characteristic curve. Four hundred ninety-one patients and 245 patients were included in the development and validation cohorts, respectively. The most parsimonious model included age, platelet count, requirement for vasopressors, requirement for hemodialysis, and nontrauma admission. The area under the receiver operator characteristic curve for the ProVent 14 model using continuous variables was 0.80 (95% CI, 0.76-0.83) in the development cohort and 0.78 (95% CI, 0.72-0.83) in the validation cohort. The ProVent 14 Score categorized age at 50 and 65 years old and platelet count at 100×10(9)/L and had similar discrimination as the ProVent 14 model in both cohorts. CONCLUSION Using clinical variables available on day 14 of mechanical ventilation, the ProVent 14 model can identify patients receiving prolonged mechanical ventilation with a high risk of mortality within 1 year.
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Miller JJ, Morris P, Files DC, Gower E, Young M. Decision conflict and regret among surrogate decision makers in the medical intensive care unit. J Crit Care 2015; 32:79-84. [PMID: 26810482 DOI: 10.1016/j.jcrc.2015.11.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/30/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Family members of critically ill patients in the intensive care unit face significant morbidity. It may be the decision-making process that plays a significant role in the psychological morbidity associated with being a surrogate in the ICU. We hypothesize that family members facing end-of-life decisions will have more decisional conflict and decisional regret than those facing non-end-of-life decisions. METHODS We enrolled a sample of adult patients and their surrogates in a tertiary care, academic medical intensive care unit. We queried the surrogates regarding decisions they had made on behalf of the patient and assessed decision conflict. We then contacted the family member again to assess decision regret. RESULTS Forty (95%) of 42 surrogates were able to identify at least 1 decision they had made on behalf of the patient. End-of-life decisions (defined as do not resuscitate [DNR]/do not intubate [DNI] or continuation of life support) accounted for 19 of 40 decisions (47.5%). Overall, the average Decision Conflict Scale (DCS) score was 21.9 of 100 (range 0-100, with 0 being little decisional conflict and 100 being great decisional conflict). The average DCS score for families facing end-of-life decisions was 25.5 compared with 18.7 for all other decisions. Those facing end-of-life decisions scored higher on the uncertainty subscale (subset of DCS questions that indicates level of certainty regarding decision) with a mean score of 43.4 compared with all other decisions with a mean score of 27.0. Overall, very few surrogates experienced decisional regret with an average DRS score of 13.4 of 100. CONCLUSIONS Nearly all surrogates enrolled were faced with decision-making responsibilities on behalf of his or her critically ill family member. In our small pilot study, we found more decisional conflict in those surrogates facing end-of-life decisions, specifically on the subset of questions dealing with uncertainty. Surrogates report low levels of decisional regret.
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Affiliation(s)
- Jesse J Miller
- Wake Forest University Baptist Medical Center, Department of Pulmonary and Critical Care, Winston Salem, NC 27012.
| | - Peter Morris
- Wake Forest University Baptist Medical Center, Department of Pulmonary and Critical Care, Winston Salem, NC 27012.
| | - D Clark Files
- Wake Forest University Baptist Medical Center, Department of Pulmonary and Critical Care, Winston Salem, NC 27012.
| | - Emily Gower
- Wake Forest School of Medicine, Department of Epidemiology and Ophthalmology, Winston Salem, NC 27012.
| | - Michael Young
- Wake Forest University Baptist Medical Center, Department of Pulmonary and Critical Care, Winston Salem, NC 27012.
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Marchioni A, Fantini R, Antenora F, Clini E, Fabbri L. Chronic critical illness: the price of survival. Eur J Clin Invest 2015; 45:1341-9. [PMID: 26549412 DOI: 10.1111/eci.12547] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 10/03/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND The evolution of the techniques used in the intensive care setting over the past decades has led on one side to better survival rates in patients with acute conditions and severely impaired vital functions. On the other side, it has resulted in a growing number of patients who survive an acute event, but who then become dependent on one or more life support techniques. Such patients are called chronically critically ill patients. MATERIALS & METHODS No absolute definition of the disease is currently available, although most patients are characterized by the need for prolonged mechanical ventilation. Mortality rates are still high even after dismissal from intensive care unit (ICU) and transfer to specialized rehabilitation care settings. RESULTS In recent years, some studies have tried to clarify the pathophysiological characteristics underlying chronic critical illness (CCI), a disease that is also characterized by severe endocrine and inflammatory impairments, partly accounting for the almost constant set of symptoms. DISCUSSION Currently, no specific treatment is available. However, a strategic early therapeutic approach on ICU admission might try to prevent the progress of the acute disease towards chronic critical illness.
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Affiliation(s)
- Alessandro Marchioni
- Respiratory Disease Clinic Department of Oncology, Haematology and Respiratory Disease, University of Modena and Reggio Emilia, Modena, Italy
| | - Riccardo Fantini
- Respiratory Disease Clinic Department of Oncology, Haematology and Respiratory Disease, University of Modena and Reggio Emilia, Modena, Italy
| | - Federico Antenora
- Respiratory Disease Clinic Department of Oncology, Haematology and Respiratory Disease, University of Modena and Reggio Emilia, Modena, Italy
| | - Enrico Clini
- Respiratory Disease Clinic Department of Oncology, Haematology and Respiratory Disease, University of Modena and Reggio Emilia, Modena, Italy
| | - Leonardo Fabbri
- Respiratory Disease Clinic Department of Oncology, Haematology and Respiratory Disease, University of Modena and Reggio Emilia, Modena, Italy
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Bice T, Nelson JE, Carson SS. To Trach or Not to Trach: Uncertainty in the Care of the Chronically Critically Ill. Semin Respir Crit Care Med 2015; 36:851-8. [PMID: 26595045 DOI: 10.1055/s-0035-1564872] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The number of chronically critically ill patients requiring prolonged mechanical ventilation and receiving a tracheostomy is steadily increasing. Early tracheostomy in patients requiring prolonged mechanical ventilation has been proposed to decrease duration of mechanical ventilation and intensive care unit stay, reduce mortality, and improve patient comfort. However, these benefits have been difficult to demonstrate in clinical trials. So how does one determine the appropriate timing for tracheostomy placement in your patient? Here we review the potential benefits and consequences of tracheostomy, the available evidence for tracheostomy timing, communication surrounding the tracheostomy decision, and a patient-centered approach to tracheostomy. Patients requiring > 10 days of mechanical ventilation who are expected to survive their hospitalization likely benefit from tracheostomy, but protocols involving routine early tracheostomy placement do not improve patient outcomes. However, patients with neurologic injury, provided they have a good prognosis for meaningful recovery, may benefit from early tracheostomy. In chronically critically ill patients with poor prognosis, tracheostomy is unlikely to provide benefit and should only be pursued if it is consistent with the patient's values, goals, and preferences. In this setting, communication with patients and surrogates regarding tracheostomy and prognosis becomes paramount. For the foreseeable future, decisions surrounding tracheostomy will remain relevant and challenging.
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Affiliation(s)
- Thomas Bice
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Judith E Nelson
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York
| | - Shannon S Carson
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Aslakson RA, Schuster ALR, Reardon J, Lynch T, Suarez-Cuervo C, Miller JA, Moldovan R, Johnston F, Anton B, Weiss M, Bridges JFP. Promoting perioperative advance care planning: a systematic review of advance care planning decision aids. J Comp Eff Res 2015; 4:615-50. [PMID: 26346494 DOI: 10.2217/cer.15.43] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
This systematic review identifies possible decision aids that promote perioperative advance care planning (ACP) and synthesizes the available evidence regarding their use. Using PubMed, EMBASE, Cochrane, SCOPUS, Web of Science, CINAHL, PsycINFO and Sociological Abstracts, researchers identified and screened articles for eligibility. Data were abstracted and risk of bias assessed for included articles. Thirty-nine of 5327 articles satisfied the eligibility criteria. Primarily completed in outpatient ambulatory populations, studies evaluated a variety of ACP decision aids. None were evaluated in a perioperative population. Fifty unique outcomes were reported with no head-to-head comparisons conducted. Findings are likely generalizable to a perioperative population and can inform development of a perioperative ACP decision aid. Future studies should compare the effectiveness of ACP decision aids.
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Affiliation(s)
- Rebecca A Aslakson
- Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Anne L R Schuster
- Department of Health Policy & Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 22105, USA
| | - Jessica Reardon
- Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Thomas Lynch
- Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Catalina Suarez-Cuervo
- The Johns Hopkins Evidence-based Practice Center, Department of Health Policy & Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Judith A Miller
- Patient/Family Member Co-investigator, Architecture by Design, Ellicott City, MD 21042, USA
| | - Rita Moldovan
- Department of Medicine Nursing, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Fabian Johnston
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Blair Anton
- William H. Welch Medical Library, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Matthew Weiss
- Department of Surgery, The Johns Hopkins University, Baltimore, MD 21287, USA
| | - John F P Bridges
- Department of Health Policy & Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 22105, USA
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Lahiri S, Navi BB, Mayer SA, Rosengart A, Merkler AE, Claassen J, Kamel H. Hospital Readmission Rates Among Mechanically Ventilated Patients With Stroke. Stroke 2015; 46:2969-71. [PMID: 26272387 DOI: 10.1161/strokeaha.115.010441] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 07/15/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Tracheostomy is frequently performed in patients with severe ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage. Little is known about readmission rates among stroke patients who undergo mechanical ventilation. METHODS We used previously validated International Classification of Diseases, Ninth Edition-Clinical Modification codes and data on all discharges from nonfederal acute care hospitals in 3 states. We compared readmission rates among mechanically ventilated patients with stroke who were discharged with or without a tracheostomy. RESULTS Among 39,881 patients who underwent mechanical ventilation during the index stroke hospitalization and survived to discharge, 10,690 (26.8%; 95% confidence interval, 26.4%-27.2%) underwent tracheostomy. During a mean follow-up period of 3.4 (±2.0) years, the overall incidence rate of readmissions was 4.25 (95% confidence interval, 4.22-4.28) per 100 patients per 30 days. The rate of any readmissions within 30 days was 26.9% among patients with tracheostomy compared with 22.5% among those without a tracheostomy (absolute risk difference, 4.4%; 95% confidence interval, 3.5%-5.4%; P<0.001). After adjustment for potentially confounding variables, tracheostomy was associated with a slightly increased readmission rate (incidence rate ratio, 1.07; 95% confidence interval, 1.03-1.11). CONCLUSIONS Approximately one quarter of mechanically ventilated patients with stroke who survive to discharge are readmitted to the hospital within 30 days. Readmission rates are significantly higher in patients with stroke who undergo tracheostomy, but the difference is not clinically meaningful. Thirty-day readmission rates among mechanically ventilated patients with stroke are similar to Medicare beneficiaries hospitalized with major medical diseases such as pneumonia.
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Affiliation(s)
- Shouri Lahiri
- From the Departments of Neurology and Neurosurgery (S.L.) and Neurology, Neurosurgery, and Biomedical Sciences (A.R.), Cedars-Sinai Medical Center, Los Angeles; Department of Neurology (B.B.N., A.E.M., H.K.), Feil Family Brain and Mind Research Institute (B.B.N., H.K.), Weill Cornell Medical College, New York, NY; Departments of Neurology and Neurosurgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, NY (S.A.M.); and Department of Neurology, Columbia College of Physicians and Surgeons, New York, NY (A.E.M., J.C.).
| | - Babak B Navi
- From the Departments of Neurology and Neurosurgery (S.L.) and Neurology, Neurosurgery, and Biomedical Sciences (A.R.), Cedars-Sinai Medical Center, Los Angeles; Department of Neurology (B.B.N., A.E.M., H.K.), Feil Family Brain and Mind Research Institute (B.B.N., H.K.), Weill Cornell Medical College, New York, NY; Departments of Neurology and Neurosurgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, NY (S.A.M.); and Department of Neurology, Columbia College of Physicians and Surgeons, New York, NY (A.E.M., J.C.)
| | - Stephan A Mayer
- From the Departments of Neurology and Neurosurgery (S.L.) and Neurology, Neurosurgery, and Biomedical Sciences (A.R.), Cedars-Sinai Medical Center, Los Angeles; Department of Neurology (B.B.N., A.E.M., H.K.), Feil Family Brain and Mind Research Institute (B.B.N., H.K.), Weill Cornell Medical College, New York, NY; Departments of Neurology and Neurosurgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, NY (S.A.M.); and Department of Neurology, Columbia College of Physicians and Surgeons, New York, NY (A.E.M., J.C.)
| | - Axel Rosengart
- From the Departments of Neurology and Neurosurgery (S.L.) and Neurology, Neurosurgery, and Biomedical Sciences (A.R.), Cedars-Sinai Medical Center, Los Angeles; Department of Neurology (B.B.N., A.E.M., H.K.), Feil Family Brain and Mind Research Institute (B.B.N., H.K.), Weill Cornell Medical College, New York, NY; Departments of Neurology and Neurosurgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, NY (S.A.M.); and Department of Neurology, Columbia College of Physicians and Surgeons, New York, NY (A.E.M., J.C.)
| | - Alexander E Merkler
- From the Departments of Neurology and Neurosurgery (S.L.) and Neurology, Neurosurgery, and Biomedical Sciences (A.R.), Cedars-Sinai Medical Center, Los Angeles; Department of Neurology (B.B.N., A.E.M., H.K.), Feil Family Brain and Mind Research Institute (B.B.N., H.K.), Weill Cornell Medical College, New York, NY; Departments of Neurology and Neurosurgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, NY (S.A.M.); and Department of Neurology, Columbia College of Physicians and Surgeons, New York, NY (A.E.M., J.C.)
| | - Jan Claassen
- From the Departments of Neurology and Neurosurgery (S.L.) and Neurology, Neurosurgery, and Biomedical Sciences (A.R.), Cedars-Sinai Medical Center, Los Angeles; Department of Neurology (B.B.N., A.E.M., H.K.), Feil Family Brain and Mind Research Institute (B.B.N., H.K.), Weill Cornell Medical College, New York, NY; Departments of Neurology and Neurosurgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, NY (S.A.M.); and Department of Neurology, Columbia College of Physicians and Surgeons, New York, NY (A.E.M., J.C.)
| | - Hooman Kamel
- From the Departments of Neurology and Neurosurgery (S.L.) and Neurology, Neurosurgery, and Biomedical Sciences (A.R.), Cedars-Sinai Medical Center, Los Angeles; Department of Neurology (B.B.N., A.E.M., H.K.), Feil Family Brain and Mind Research Institute (B.B.N., H.K.), Weill Cornell Medical College, New York, NY; Departments of Neurology and Neurosurgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, NY (S.A.M.); and Department of Neurology, Columbia College of Physicians and Surgeons, New York, NY (A.E.M., J.C.)
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Abstract
OBJECTIVE To review how disability can develop in older adults with critical illness and to explore ways to reduce long-term disability following critical illness. DATA SOURCES We searched PubMed, CINAHL, Web of Science and Google Scholar for studies reporting disability outcomes (i.e., activities of daily living, instrumental activities of daily living, and mobility activities) and/or cognitive outcomes among patients treated in an ICU who were 65 years or older. We also reviewed the bibliographies of relevant citations to identify additional citations. STUDY SELECTION We identified 19 studies evaluating disability outcomes in critically ill patients who were 65 years and older. DATA EXTRACTION Descriptive epidemiologic data on disability after critical illness. DATA SYNTHESIS Newly acquired disability in activities of daily living, instrumental activities of daily living, and mobility activities was commonplace among older adults who survived a critical illness. Incident dementia and less severe cognitive impairment were also highly prevalent. Factors related to the acute critical illness, ICU practices, such as heavy sedation, physical restraints, and immobility, as well as aging physiology, and coexisting geriatric conditions can combine to result in these poor outcomes. CONCLUSIONS Older adults who survive critical illness have physical and cognitive declines resulting in disability at greater rates than hospitalized, noncritically ill and community dwelling older adults. Interventions derived from widely available geriatric care models in use outside of the ICU, which address modifiable risk factors including immobility and delirium, are associated with improved functional and cognitive outcomes and can be used to complement ICU-focused models such as the ABCDEs.
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Allareddy V, Rampa S, Nalliah RP, Martinez-Schlurmann NI, Lidsky KB, Allareddy V, Rotta AT. Prevalence and Predictors of Gastrostomy Tube and Tracheostomy Placement in Anoxic/Hypoxic Ischemic Encephalopathic Survivors of In-Hospital Cardiopulmonary Resuscitation in the United States. PLoS One 2015. [PMID: 26197229 PMCID: PMC4510456 DOI: 10.1371/journal.pone.0132612] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Introduction Current prevalence estimates of gastrostomy tube (GT) /tracheostomy placement in hospitalized patients with anoxic/hypoxic ischemic encephalopathic injury (AHIE) post cardiopulmonary resuscitation (CPR) are unknown. We sought, to estimate the prevalence of AHIE in hospitalized patients who had CPR and to identify patient/hospital level factors that predict the performance of GT/tracheostomy in those with AHIE. Methods We performed a retrospective analysis of the Nationwide Inpatient Sample (years 2004–2010). All patients who developed AHIE following CPR were included. In this cohort the odds of having GT and tracheostomy was computed by multivariable logistic regression analysis. Patient and hospital level factors were the independent variables. Results During the study period, a total of 686,578 CPR events occurred in hospitalized patients. Of these, 94,336 (13.7%) patients developed AHIE. In this AHIE cohort, 6.8% received GT and 8.3% tracheostomy. When compared to the 40–49 yrs age group, those aged >70 yrs were associated with lower odds for GT (OR = 0.65, 95% CI:0.53–0.80, p<0.0001). Those aged <18 years & those >60 years were associated with lower odds for having tracheostomy when compared to the 40–49 years group (p<0.0001). Each one unit increase in co-morbid burden was associated with higher odds for having GT (OR = 1.23,p<0.0001) or tracheostomy (OR = 1.17, p<0.0001). Blacks, Hispanics, Asians/Pacific Islanders, and other races were associated with higher odds for having GT or tracheostomy when compared to whites (p<0.05). Hospitals located in northeastern regions were associated with higher odds for performing GT (OR = 1.48, p<0.0001) or tracheostomy (OR = 1.63, p<0.0001) when compared to those in Western regions. Teaching hospitals (TH) were associated with higher odds for performing tracheostomy when compared to non-TH (OR = 1.36, 1.20–1.54, p<0.0001). Conclusions AHIE injury occurs in a significant number of in-hospital arrests requiring CPR. Certain predictors of GT/ Tracheostomy placement are identified. Patients in teaching hospitals were more likely to receive tracheostomy than their counterparts.
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Affiliation(s)
- Veerajalandhar Allareddy
- UH Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio, United States of America
- * E-mail:
| | - Sankeerth Rampa
- University of Nebraska, Health Services and Research department, Omaha, Nebraska, United States of America
| | - Romesh P. Nalliah
- University of Michigan, College of Dentistry, Ann Arbor, Michigan, United States of America
| | | | - Karen B. Lidsky
- UH Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - Veerasathpurush Allareddy
- University of Iowa, School of Dentistry, College of Dentistry and Dental Clinics, Iowa City, Iowa, United States of America
| | - Alexandre T. Rotta
- UH Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio, United States of America
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Long-term survival of critically ill patients treated with prolonged mechanical ventilation: a systematic review and meta-analysis. THE LANCET RESPIRATORY MEDICINE 2015; 3:544-53. [DOI: 10.1016/s2213-2600(15)00150-2] [Citation(s) in RCA: 150] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 04/11/2015] [Accepted: 04/14/2015] [Indexed: 11/18/2022]
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Rosenthal MD, Moore FA. Persistent inflammatory, immunosuppressed, catabolic syndrome (PICS): A new phenotype of multiple organ failure. ACTA ACUST UNITED AC 2015; 1. [PMID: 26086042 DOI: 10.14800/janhm.784] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A new phenotype of multiple organ failure has appeared: Persistent Inflammatory, Immunosuppressed, Catabolic Syndrome (PICS). Comorbidities and age >65 years have been established as the leading risk factors for PICS. As the percentage of elderly people continues to increase the prevalence of PICS in our ICUs will surely grow. Malnutrition (despite appropriate supplementation), recurrent nosocomial infections, frailty, ventilator dependence, and an indolent death depicts the central theme that plagues PICS patients. Aligned with the recently awarded P50 grant by NIGMS entitled, "PICS: A New Horizon for Surgical Critical Care", and the University Of Florida's Sepsis and Critical Illness Research Center will investigate the genetic make-up of PICS patients, better understand frailty and the implication in trauma patients, and hopefully elucidate new therapies. Currently, there are no therapies to combat PICS aside from nutritional inference elaborated after reviewing the literature on Burns, Cachexia, and Sarcopenia.
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Affiliation(s)
- Martin D Rosenthal
- Departments of Surgery, Division of Acute Care Surgery and Center For Sepsis and Critical Illness Research, University of Florida College of Medicine; Gainesville, Florida
| | - Frederick A Moore
- Departments of Surgery, Division of Acute Care Surgery and Center For Sepsis and Critical Illness Research, University of Florida College of Medicine; Gainesville, Florida
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50
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Measuring "quality": what do patient- and surrogate-perceived assessments of communication actually mean? Crit Care Med 2015; 43:700-1. [PMID: 25700054 DOI: 10.1097/ccm.0000000000000760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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