Follow-up after intensive care: a single center study

Models of intensive care unit follow-up care and feasibility of intervention delivery: A systematic review

BACKGROUND

The optimal model of outpatient intensive care unit (ICU) follow-up care remains uncertain, and there is limited evidence of benefit.

RESEARCH QUESTION

The objective of this research is to describe existing models of outpatient ICU follow-up care, quantify participant recruitment and retention, and describe facilitators of patient engagement.

STUDY DESIGN & METHODS

A systematic search of the MEDLINE and EMBASE databases was undertaken in June 2021. Two independent reviewers screened titles, abstracts, and full texts against eligibility criteria. Studies of adults with any outpatient ICU follow-up were included. Studies were excluded if published before 1990, not published in English, or of paediatric patients. Quantitative data were extracted using predefined data fields. Key themes were extracted from qualitative studies. Risk of bias was assessed.

RESULTS

A total of 531 studies were screened. Forty-seven studies (32 quantitative and 15 qualitative studies) with a total of 5998 participants were included. Of 33 quantitative study interventions, the most frequently reported model of care was in-person hospital-based interventions (n = 27), with 10 hybrid (part in-hospital, part remote) interventions. Literature was limited for interventions without hospital attendance (n = 6), including telehealth and diaries. The median ranges of rates of recruitment, rates of intervention delivery, and retention to outcome assessment for hospital-based interventions were 51.5% [24-94%], 61.9% [8-100%], and 52% [8.1-82%], respectively. Rates were higher for interventions without hospital attendance: 82.6% [60-100%], 68.5% [59-89%], and 75% [54-100%]. Facilitators of engagement included patient-perceived value of follow-up, continuity of care, intervention accessibility and flexibility, and follow-up design. Studies had a moderate risk of bias.

INTERPRETATION

Models of post-ICU care without in-person attendance at the index hospital potentially have higher rates of recruitment, intervention delivery success, and increased participant retention when compared to hospital-based interventions.

PROSPERO REGISTRATION

CRD42021260279.

Body composition and muscle strength at the end of ICU stay are associated with 1-year mortality, a prospective multicenter observational study

BACKGROUND & AIMS

After a prolonged intensive care unit (ICU) stay patients experience increased mortality and morbidity. The primary aim of this study was to assess the prognostic value of nutritional status, body mass composition and muscle strength, as assessed by body mass index (BMI), bioelectrical impedance analysis (BIA), handgrip (HG) test, and that of the biological features to predict one-year survival at the end of a prolonged ICU stay.

METHODS

This was a multicenter prospective observational study. Survivor patients older than 18 years with ICU length of stay >72 h were eligible for inclusion. BIA and HG were performed at the end of the ICU stay. Malnutrition was defined by BMI and fat-free mass index (FFMI). The primary endpoint was one-year mortality. Multivariable logistic regression was performed to determine parameters associated with mortality.

RESULTS

572 patients were included with a median age of 63 years [53.5; 71.1], BMI of 26.6 kg/m2 [22.8; 31.3], SAPS II score of 43 [31; 58], and ICU length of stay of 9 days [6; 15]. Malnutrition was observed in 142 (24.9%) patients. During the 1-year follow-up after discharge, 96 (18.5%) patients died. After adjustment, a low HG test score (aOR = 1.44 [1.11; 1.89], p = 0.01) was associated with 1-year mortality. Patients with low HG score, malnutrition, and Albuminemia <30 g/L had a one-year death rate of 41.4%. Conversely, patients with none of these parameters had a 1-year death rate of 4.1%.

CONCLUSION

BIA to assess FFMI, HG and albuminemia at the end of ICU stay could be used to predict 1-year mortality. Their ability to identify patients eligible for a structured recovery program could be studied.

Organization, feasibility and patient appreciation of a follow-up consultation in surgical critically ill patients with favorable baseline quality of life and prolonged ICU-stay: a pilot study

OBJECTIVES

Intensive care unit (ICU) survivors are often left with impairments in physical, mental and cognitive functioning (Post-Intensive Care Syndrome (PICS)). We evaluated the organization, the feasibility for caregivers and patients and the patients' appreciation of a post-ICU consultation aiming to detect these PICS-symptoms.

METHODS

A single-center prospective observational pilot study was conducted during an 18 month-period in the surgical ICU of a tertiary care hospital. Consecutive adult patients with an ICU-stay of ≥8 days and a favorable baseline quality of life (utility index ≥0.6 on EQ-5D-3 L) were eligible for inclusion. A post-ICU follow-up consultation consisting of a structured interview was scheduled 3 months after hospital discharge. Characteristics of the consultation (CG) and no consultation group (NCG) were compared. P-values <0.05 were considered significant.

RESULTS

Of 133 eligible patients, 85 (64%) consented for the study and 42 (49%) attended the consultation. A total of 148 phone calls were made to schedule the consultations. Consultations took a median of 68 (61-74) minutes. Compared to CG-patients, NCG-patients were more often discharged to a care facility (P = 0.003) and had more problems with mobility (P = 0.014), self-care (P < 0.001) and usual activities (P = 0.005) after 3 months. At least one PICS-related problem was documented in all patients in the CG and NCG. Thirty-four CG-patients (81%) appreciated the initiative.

CONCLUSION

Organizing an ICU-follow-up consultation was difficult and feasibility was low, but most attending patients appreciated the initiative. Better developed structures for ICU-follow-up are needed in view of the high number of PICS-related problems documented.

The role of nutrition rehabilitation in the recovery of survivors of critical illness: underrecognized and underappreciated

Many survivors of critical illness face significant physical and psychological disability following discharge from the intensive care unit (ICU). They are often malnourished, a condition associated with poor outcomes, and nutrition remains problematic particularly in the early phases of ICU recovery. Yet nutrition rehabilitation, the process of restoring or optimizing nutritional status following illness, is seldom prioritized, possibly because it is an underrecognized and underappreciated area in critical care rehabilitation and research. To date, 16 original studies have been published where one of the objectives includes measurement of indices relating to nutritional status (e.g., nutrition intake or factors impacting nutrition intake) in ICU survivors. The primary aim of this narrative review is to provide a comprehensive summary of key themes arising from these studies which form the basis of our current understanding of nutritional recovery and rehabilitation in ICU survivors. ICU survivors face a multitude of barriers in achieving optimal nutrition that are of physiological (e.g., poor appetite and early satiety), functional (e.g., dysphagia, reduced ability to feed independently), and psychological (e.g., low mood, body dysmorphia) origins. Organizational-related barriers such as inappropriate feeding times and meal interruptions frequently impact an ICU survivor’s ability to eat. Healthcare providers working on wards frequently lack knowledge of the specific needs of recovering critically ill patients which can negatively impact post-ICU nutrition care. Unsurprisingly, nutrition intake is largely inadequate following ICU discharge, with the largest deficits occurring in those who have had enteral nutrition prematurely discontinued and rely on an oral diet as their only source of nutrition. With consideration to themes arising from this review, pragmatic strategies to improve nutrition rehabilitation are explored and directions for future research in the field of post-ICU nutrition recovery and rehabilitation are discussed. Given the interplay between nutrition and physical and psychological health, it is imperative that enhancing the nutritional status of an ICU survivor is considered when developing multidisciplinary rehabilitation strategies. It must also be recognized that dietitians are experts in the field of nutrition and should be included in stakeholder meetings that aim to enhance ICU rehabilitation strategies and improve outcomes for survivors of critical illness.

Recovery, rehabilitation and follow-up services following critical illness: an updated UK national cross-sectional survey and progress report

OBJECTIVE

To comprehensively update and survey the current provision of recovery, rehabilitation and follow-up services for adult critical care patients across the UK.

DESIGN

Cross-sectional, self-administered, predominantly closed-question, electronic, online survey.

SETTING

Institutions providing adult critical care services identified from national databases.

PARTICIPANTS

Multiprofessional critical care clinicians delivering services at each site.

RESULTS

Responses from 176 UK hospital sites were included (176/242, 72.7%). Inpatient recovery and follow-up services were present at 127/176 (72.2%) sites, adopting multiple formats of delivery and primarily delivered by nurses (n=115/127, 90.6%). Outpatient services ran at 130 sites (73.9%), predominantly as outpatient clinics. Most services (n=108/130, 83.1%) were co-delivered by two or more healthcare professionals, typically nurse/intensive care unit (ICU) physician (n=29/130, 22.3%) or nurse/ICU physician/physiotherapist (n=19/130, 14.6%) teams. Clinical psychology was most frequently lacking from inpatient or outpatient services. Lack of funding was consistently the primary barrier to service provision, with other barriers including logistical and service prioritisation factors indicating that infrastructure and profile for services remain inadequate. Posthospital discharge physical rehabilitation programmes were relatively few (n=31/176, 17.6%), but peer support services were available in nearly half of responding institutions (n=85/176, 48.3%). The effects of the COVID-19 pandemic resulted in either increasing, decreasing or reformatting service provision. Future plans for long-term service transformation focus on expansion of current, and establishment of new, outpatient services.

CONCLUSION

Overall, these data demonstrate a proliferation of recovery, follow-up and rehabilitation services for critically ill adults in the past decade across the UK, although service gaps remain suggesting further work is required for guideline implementation. Findings can be used to enhance survivorship for critically ill adults, inform policymakers and commissioners, and provide comparative data and experiential insights for clinicians designing models of care in international healthcare jurisdictions.

General practitioners' views and experiences in caring for patients after sepsis: a qualitative interview study

BACKGROUND

Patients surviving critical illnesses, such as sepsis, often suffer from long-term complications. After discharge from hospital, most patients are treated in primary care. Little is known how general practitioners (GPs) perform critical illness aftercare and how it can be improved. Within a randomised controlled trial, an outreach training programme has been developed and applied.

OBJECTIVES

The aim of this study is to describe GPs' views and experiences of caring for postsepsis patients and of participating a specific outreach training.

DESIGN

Semistructured qualitative interviews.

SETTING

14 primary care practices in the metropolitan area of Berlin, Germany.

PARTICIPANTS

14 GPs who had participated in a structured sepsis aftercare programme in primary care.

RESULTS

Themes identified in sepsis aftercare were: continuity of care and good relationship with patients, GP's experiences during their patient's critical illness and impact of persisting symptoms. An outreach education as part of the intervention was considered by the GPs to be acceptable, helpful to improve knowledge of the management of postintensive care complications and useful for sepsis aftercare in daily practice.

CONCLUSIONS

GPs provide continuity of care to patients surviving sepsis. Better communication at the intensive care unit-GP interface and training in management of long-term complications of sepsis may be helpful to improve sepsis aftercare.

TRIAL REGISTRATION NUMBER

ISRCTN61744782.

Outcomes after percutaneous dilatation tracheostomy: Patients view 6 years after the procedure

BACKGROUND

Percutaneous dilatational tracheostomy have been performed increasingly since its introduction in 1985, and is today one of the most commonly performed operative procedures in intensive care units. The aim of this study was to document patient-reported outcomes from percutaneous dilatational tracheostomy after hospital discharge.

METHODS

This study is based on retrospective extraction of data from the databases in the ICU at Haukeland University Hospital from 2004 to 2016. Patients alive by April 2018 and with a code for dilatation tracheostomy were sent a questionnaire about their experiences with having a tracheostomy performed. The occurrence of problems and their relations were registered.

RESULTS

Of 5769 admitted patients, 900 patients ≥ 15 years (15.7%) had a percutaneous dilatation tracheostomy performed. The median time from admission to follow-up was 6.1 years, and the 30 days mortality in those who received a tracheostomy was 315/900 (35%). Of the 441 survivors contacted, 181 answered the questionnaire and a total of 293 problems were reported. The majority of these problems were reported as no or moderate in 115 patients (78.3%). The presence of any problem was significantly associated with occurrence for other problems; however, there were no significant differences related to the elapsed time since the ICU stay. Pain and difficulties with breathing were the two single factors most often related to occurrence of other problems.

CONCLUSION

Although self-reported problems after percutaneous tracheostomy occurring after hospital discharge were often reported, most (78.3%) were considered by the patients to be moderate.

Avaliação psicológica de pacientes após a alta da unidade de terapia intensiva

A maioria dos pacientes sobrevive ao episódio de doença crítica, contudo, muitos deles podem desenvolver alterações psicológicas após a alta desta unidade. Dada a natureza dos cuidados intensivos e as condições clínicas da maioria dos pacientes esta pesquisa tem como objetivo descrever os resultados da avaliação psicológica de pacientes três meses após a alta dos cuidados críticos. Foram avaliados 160 pacientes, no entanto, devido ao comprometimento neurológico apenas 137 conseguiram responder à avaliação psicológica. Os instrumentos utilizados foram: Planilha para coleta de dados do prontuário, instrumento de avaliação de memórias de UTI, Impact of Event Scale-Revised (IES-R) e Escala Hospitalar de Ansiedade e Depressão (HADS). Os resultados revelaram que a identificação precoce das complicações inerentes ao tratamento crítico poderá trazer benefícios para a prevenção de alterações emocionais/físicas crônicas subsequentes.

Nutrition Risk Screening in Intensive Care Units: Agreement Between NUTRIC and NRS 2002 Tools

BACKGROUND

The American Society for Parenteral and Enteral Nutrition recommends nutrition screening in patients admitted to the intensive care unit (ICU) and indicates the use of 2 tools: Nutritional Risk Screening 2002 (NRS 2002) or Nutrition Risk in the Critically Ill (NUTRIC). This study aims to compare nutrition risk detected by NRS 2002 and NUTRIC to identify whether both tools are equivalent for clinical practice in the ICU.

METHODS

A retrospective cohort study was conducted in 2 hospital centers in the south of Brazil. Adult patients (≥18 years old) who stayed in the ICU for >24 hours were included. NUTRIC and NRS 2002 were compared with each other for their agreement in screening for nutrition risk.

RESULTS

The study included 208 patients, most of them male (63.5%). The comparison between both nutrition screening tools showed fair agreement (κ = 0.39). Nearly half of the patients were classified at high nutrition risk by NUTRIC (47.6%), whereas only approximately one-third of the sample was classified similarly by NRS 2002 (35.6%).

CONCLUSION

Despite the ability to identify patients with high nutrition risk, NUTRIC and NRS 2002 performed differently and were not concordant, suggesting that are not equivalent for clinical practice in the ICU.

Implementation of an ICU Recovery Clinic at a Tertiary Care Academic Center

Post-ICU clinics may facilitate the care of survivors of critical illness, but there is a paucity of data describing post-ICU clinic implementation. We sought to describe implementation of our ICU recovery clinic, including an assessment of barriers and facilitators to clinic attendance.

DESIGN

Adults admitted to the medical ICU of a large tertiary care academic hospital with shock and/or respiratory failure requiring mechanical ventilation were screened for participation in a newly formed ICU recovery clinic. Participant selection and attendance rates were tracked. Reasons for nonattendance were assessed by phone call in a subset of patients.

SETTING

A newly formed ICU recovery clinic of a large tertiary care academic hospital.

PATIENTS

All patients admitted to the medical ICU were screened.

INTERVENTIONS

ICU recovery clinic appointments were scheduled for all eligible patients. A subset of nonattenders were called to assess reasons for nonattendance.

MEASUREMENTS AND MAIN RESULTS

Over 2 years, we admitted 5,510 patients to our medical ICU. Three hundred sixty-two were screened into the recovery clinic. One-hundred sixty-six were not scheduled for clinic; major reasons included discharge to hospice/death in the hospital (n = 55) and discharge to a facility (n = 50). One-hundred ninety-six patients were scheduled for a visit and of those, 101 (52%) arrived to clinic. Reasons for nonattendance in a surveyed subset of nonattenders included patient's lack of awareness of the appointment (50%, n = 9/18), financial concerns (17%, n = 3/18), and transportation difficulty (17%, n = 3/18).

CONCLUSIONS

ICU recovery clinics may address the needs of survivors of critical illness. Barriers to clinic attendance include high mortality rates, high rates of clinic appointment cancelations and nonattendance, and discharge to locations such as skilled nursing facilities or long-term acute care hospitals. Improved communication to patients about the role of the clinic may facilitate attendance and minimize canceled appointments.

Post-intensive care outpatient clinic: is it feasible and effective? A literature review

The follow-up of patients who are discharged from intensive care units follows distinct flows in different parts of the world. Outpatient clinics or post-intensive care clinics represent one of the forms of follow-up, with more than 20 years of experience in some countries. Qualitative studies that followed up patients in these outpatient clinics suggest more encouraging results than quantitative studies, demonstrating improvements in intermediate outcomes, such as patient and family satisfaction. More important results, such as mortality and improvement in the quality of life of patients and their families, have not yet been demonstrated. In addition, which patients should be indicated for these outpatient clinics? How long should they be followed up? Can we expect an improvement of clinical outcomes in these followed-up patients? Are outpatient clinics cost-effective? These are only some of the questions that arise from this form of follow-up of the survivors of intensive care units. This article aims to review all aspects relating to the organization and performance of post-intensive care outpatient clinics and to provide an overview of studies that evaluated clinical outcomes related to this practice.

Observed appetite and nutrient intake three months after ICU discharge

BACKGROUND & AIMS

Oral intake is diminished immediately after ICU discharge, yet factors affecting nutritional intake after hospital discharge have not been evaluated. The aim of this study was to evaluate dietary intake and factors which may influence intake - appetite and gastric emptying - 3-months after ICU discharge.

METHODS

Inception cohort study with ICU survivors compared to healthy subjects. Following an overnight fast, all participants consumed a standardized carbohydrate drink, containing ¹³C-octanoic acid, to measure gastric emptying. Dietary intake was assessed by recall of the preceding day and a standard weighed buffet meal 4-h post-drink. Appetite was assessed pre-drink (fasting) and pre- and post-buffet using visual analogue scales.

RESULTS

Fifty-one ICU survivors (82% male; 70 ± 9 y; BMI 28 ± 6 kg/m²) and 25 healthy subjects (60% male; 67 ± 12 y; BMI 27 ± 4 kg/m²) were evaluated. From the 24-h recall ICU survivors consumed less calories (ICU 1876 (708) vs. healthy subjects 2291 (834) kcal; p = 0.025) with no difference in macronutrient intake, however reported a lower preference for fat (p < 0.001). Calorie and macronutrient intake from the weighed buffet was similar between groups: calories (ICU: 658 (301) vs. healthy subjects: 736 (325) kcal; p = 0.149); protein (ICU: 37 (19) vs. healthy subjects: 40 (17) g; p = 0.275); fat (ICU: 23 (12) vs healthy subjects: 26 (13) g; p = 0.261); and carbohydrates (ICU: 69 (35) vs. healthy subjects: 79 (42) g; p = 0.141). ICU survivors reported feeling less full regardless of time-point (p = 0.041). There was no difference in the rate of gastric emptying between the two groups (p = 0.216).

CONCLUSIONS

ICU survivors reported less preference for fat and less calorie consumption than healthy subjects. However, intake of calories and macronutrients at a weighed meal was similar in the two groups, as was the rate of gastric emptying. ICU survivors reported being less full after the test meal, suggesting factors other than appetite may influence intake.

Prognostic value of respiratory quotients in severe polytrauma patients with nutritional support

OBJECTIVE

The association between energy metabolism and prognosis in polytrauma patients has not yet been defined. The aim of this study was to describe energy metabolism and analyze the prognostic value of respiratory quotient (RQ) and nonprotein respiratory quotient (npRQ) in fasting polytrauma patients (fPP) and polytrauma patients with nutritional support (nsPP).

METHODS

Twenty-two polytrauma patients (before and after parenteral nutrition administration) and 22 healthy controls (after overnight fasting) were examined on day 4 (median) after admission to the intensive care unit. To evaluate energy expenditure in nsPP and resting energy expenditure in fPP and controls with RQ and npRQ in all groups, we used indirect calorimetry. With regression analysis, the descriptive models of intensive care unit (ICU) length of stay (LOS) and mechanical ventilation time (VT) were derived.

RESULTS

RQ and npRQ were significantly lower in fPP than in controls (P < 0.05 and P < 0.01, respectively) and in nsPP (P < 0.05). In nsPP, relationships between RQ or npRQ and the ICU LOS or mechanical VT were demonstrated (P < 0.0001, r = -0.78 for RQ and VT; P < 0.0001, r = -0.78 for npRQ and VT; P < 0.001, r = -0.69 for RQ and LOS; P < 0.001, r = -0.72 for npRQ and LOS).

CONCLUSIONS

RQ and npRQ parameters measured by indirect calorimetry in polytrauma patients with parenteral nutrition on the fourth day of ICU stay related to clinical outcomes such as duration of mechanical ventilation and ICU LOS.

Energy, Protein, Carbohydrate, and Lipid Intakes and Their Effects on Morbidity and Mortality in Critically Ill Adult Patients: A Systematic Review

The guidelines for nutritional support in critically ill adult patients differ in various aspects. The optimal amount of energy and nutritional substrates supplied is important for reducing morbidity and mortality, but unfortunately this is not well known, because the topic is complex and every patient is individual. The aim of this review was to gather recent pertinent information concerning the nutritional support of critically ill patients in the intensive care unit (ICU) with respect to the energy, protein, carbohydrate, and lipid intakes and the effect of their specific utilization on morbidity and mortality. Enteral nutrition (EN) is generally recommended over parenteral nutrition (PN) and is beneficial when administered within 24-48 h after ICU admission. In contrast, early PN does not provide substantial advantages in terms of morbidity and mortality, and the time when it is safe and beneficial remains unclear. The most advantageous recommendation seems to be administration of a hypocaloric (<20 kcal · kg^-1 · d^-1), high-protein diet (amino acids at doses of ≥2 g · kg^-1 · d^-1), at least during the first week of critical illness. Another important factor for reducing morbidity is the maintenance of blood glucose concentrations at 120-150 mg/dL, which is accomplished with the use of insulin and lower doses of glucose of 1-2 g · kg^-1 · d^-1, because this prevents the risk of hypoglycemia and is associated with a better prognosis according to recent studies. A fat emulsion is used as a source of required calories because of insulin resistance in the majority of patients. In addition, lipid oxidation in these patients is ∼25% higher than in healthy subjects.

Critical Care Follow-up Clinics: A Scoping Review of Interventions and Outcomes

OBJECTIVE

The purpose of this scoping review is to identify evidence describing benefits of interventions provided in intensive care unit (ICU) survivor follow-up clinics.

BACKGROUND

Advances in ICU treatments have increased the number of survivors who require specialized care for ICU-related sequelae. Intensive care unit survivor follow-up clinics exist, yet little is known about the nature and impact of interventions provided in such clinics. A scoping review of publications about in-person post-ICU follow-up care was undertaken.

METHOD

Ten databases were searched yielding 111 relevant unique publication titles and abstracts. Sample heterogeneity supported using a scoping review method. After excluding nonrelated publications, 33 reports were fully reviewed. Twenty international publications were included that described ICU follow-up clinic interventions and/or outcomes.

RESULTS

Authors discussed very diverse interventions in 15 publications, and 9 reported some level of intervention effectiveness. Evidence was strongest that supported the use of prospective diaries as an intervention to prevent or improve psychological symptoms, whereas evidence to support implementation of other interventions was weak.

CONCLUSIONS

Although ICU follow-up clinics exist, evidence for interventions and effectiveness of treatments in these clinics remains underexplored.

IMPLICATIONS

Intensive care unit survivor follow-up clinics provide a venue for further interdisciplinary intervention research that could lead to better health outcomes for ICU survivors.

Physiological changes associated with routine nursing procedures in critically ill are common: an observational pilot study

BACKGROUND

Nursing procedures that are routinely performed in the intensive care unit (ICU) are assumed to have minimal side effects. However, these procedures may sometimes cause physiological changes that negatively affect the patient. We hypothesized that physiological changes associated with routine nursing procedures in the ICU are common.

METHODS

A clinical observational study of 16 critically ill patients in a nine-bed mixed university hospital ICU. All nursing procedures were observed, and physiological data were collected and subsequently analyzed. Minor physiological changes were defined as minimal changes in respiratory or circulatory variables, and major physiological changes were marked as hyper/hypotension, bradycardia/tachycardia, bradypnea/tachypnea, ventilatory distress, and peripheral blood oxygen desaturation.

RESULTS

In the 16 patients, 668 procedures generated 158 major and 692 minor physiological changes during 187 observational hours. The most common procedure was patient position change, which also generated the majority of the physiological changes. The most common major physiological changes were blood oxygen desaturation, ventilatory distress, and hypotension, and the most common minor changes were arterial pressure alteration, coughing, and increase in respiratory rate.

CONCLUSION

In this pilot study, we examined physiological changes in connection with all regular routine nursing procedures in the ICU. We found that physiological changes were common and sometimes severe.

Interruptions in enteral nutrition delivery in critically ill patients and recommendations for clinical practice

Malnutrition is common in critically ill patients and is associated with poor outcomes for patients and increased health care spending. Enteral nutrition is the method of choice for nutrition delivery. Enteral nutrition delivery practices vary widely, and underfeeding is widespread in critical care. Interruptions in enteral nutrition due to performance of procedures, positioning, technical issues with feeding accesses, and gastrointestinal intolerance contribute to underfeeding. Strategies such as head-of-bed positioning, use of prokinetic agents, tolerance of higher gastric residual volumes, consideration of postpyloric feeding access, and use of a nutrition support protocol may decrease time spent without nutrition.

[Variation of muscle mass and weight in critical patient]

OBJECTIVES

Quantify the muscle mass and body weight variation in critically ill patients and to identify associated factors.

METHOD

A descriptive follow-up study. Data for demographic variables, body weight, fluid balance, daily kilocalories, the amount of sedation and muscle relaxants received and motor physiotherapy applied were collected. Three consecutive measurements were performed in the brachial biceps and quadriceps rectus by using ultrasound, upon admission and every 5 days until discharge.

RESULTS

68 patients were included. Average age was of 73.5 [57-78,5] years. The median length of stay was 9.5 [5.5 -15] days. The median 16 (SD=5.7) daily kilocalories per kg/weight, 91.2% received sedation, 44.1% received muscle relaxants and 20% received physiotherapy. The patients presented a muscle wasting of 4.9 (SD=3.9)mm, p <.001 in the brachial biceps and 5.6 (SD=4.8)mm, p <.001 in the quadriceps rectus. Regression analysis selected the length of stay and the muscle relaxants are the most influential variables in the brachial biceps muscle wasting (R2=0.4), and length of stay as the most influential in the quadriceps rectus muscle wasting (R2=0.3). Patient's mean body weight on admission was of 81.1 (SD=15)kg and 81.2 (SD=14.2)kg on discharge, p=.95.

CONCLUSIONS

The critically ill patient presents a significant muscle waste related with the length of stay and the treatment received with muscle relaxants. Patients are being discharged with a similar body weight to which they were admitted but with a significant reduction of muscle mass.

Follow-up visit in an ICU: receiving a sense of coherence

AIM

To describe patients' experiences of a follow-up visit to an intensive care unit (ICU) after being critically ill and nursed there.

BACKGROUND

Knowledge about the follow-up visit needs to be developed, with the previously critically ill patient in focus.

DESIGN

Qualitative descriptive.

METHOD

Semi-structured interviews were conducted with nine patients and analysed using qualitative content analysis. The data collection occurred during spring 2014.

FINDINGS

During the follow-up visits in ICU, the relatives, the patient diary, and those who took part in the care contribute to fill memory gaps to create a picture and an explanation of the care period.

CONCLUSION

The follow-up visit is an important tool in the patients' struggle to create a context and coherence from a missing or unreal time. The patient diary is essential to subsequently be able to relate to the period of care.

RELEVANCE TO CLINICAL PRACTICE

The follow-up visit, together with a personal diary, after an ICU stay could be seen as significant for strengthening the patients' feeling of coherence and better health.

Nutrition support protocols and their influence on the delivery of enteral nutrition: a systematic review

BACKGROUND

Malnutrition remains prevalent in critically ill adults and is associated with poor outcomes and increased cost of hospitalization.

AIM

To (a) determine whether implementation of a nutrition support protocol improves delivery of nutrients in critically ill patients, and (b) evaluate whether patients receiving nutrition support based on a protocol have better outcomes than those who do not.

METHODS

CINHAL and PUBMED databases were searched utilizing keywords "model," "nutrition," intensive care," "algorithm," "critical care," "protocol," and "feeding guidelines." Selection criteria included original studies published in English with publication date between January 1, 2005, and December 31, 2010; a critically ill adult population; and level 1 or 2 studies. Studies were collected and reviewed by a single reviewer. Data extraction and quality assessment were assured utilizing a standardized form. A narrative description of results was provided due to variability in methods and outcome measures of included studies.

RESULTS

Ninety-nine studies emerged and 22 studies were considered for inclusion. Four studies were selected. Use of a nutrition support protocol was found to lead to increased efficacy in the delivery of nutrients via the enteral route.

LINKING EVIDENCE TO ACTION

The use of a nutrition support protocol appears to increase the efficacy of enteral nutrition delivery. Further research is needed to determine the effect of increased enteral nutrition adequacy on patient outcomes. The use of an evidenced-based protocol is recommended to improve protein and energy delivery in the critically ill.

Health-related quality of life scores after intensive care are almost equal to those of the normal population: a multicenter observational study

INTRODUCTION

Health-related quality of life (HRQoL) in patients treated in intensive care has been reported to be lower compared with age- and sex-adjusted control groups. Our aim was to test whether stratifying for coexisting conditions would reduce observed differences in HRQoL between patients treated in the ICU and a control group from the normal population. We also wanted to characterize the ICU patients with the lowest HRQoL within these strata.

METHODS

We did a cross-sectional comparison of scores of the short-form health survey (SF-36) questionnaire in a multicenter study of patients treated in the ICU (n = 780) and those from a local public health survey (n = 6,093). Analyses were in both groups adjusted for age and sex, and data stratified for coexisting conditions. Within each stratum, patients with low scores (below -2 SD of the control group) were identified and characterized.

RESULTS

After adjustment, there were minor and insignificant differences in mean SF-36 scores between patients and controls. Eight (n = 18) and 22% (n = 51) of the patients had low scores (-2 SD of the control group) in the physical and mental dimensions of SF-36, respectively. Patients with low scores were usually male, single, on sick leave before admission to critical care, and survived a shorter time after being in ICU.

CONCLUSIONS

After adjusting for age, sex, and coexisting conditions, mean HRQoL scores were almost equal in patients and controls. Up to 22% (n = 51) of the patients had, however, a poor quality of life as compared with the controls (-2 SD). This group, which more often consisted of single men, individuals who were on sick leave before admission to the ICU, had an increased mortality after ICU. This group should be a target for future support.

Intensive care delirium - effect on memories and health-related quality of life - a follow-up study

AIMS AND OBJECTIVES

To investigate the effects of delirium in the intensive care unit on health-related quality of life, healthcare dependency and memory after discharge and to explore the association between health-related quality of life and memories, patient diaries and intensive care unit follow-up.

BACKGROUND

Up to 83% of intensive care unit patients experience delirium. In addition to increased risk of mortality, morbidity and cognitive impairment, the experience itself is unpleasant. A number of studies have focused on memories associated with delirium, but the association between delirium, memories and health-related quality needs further investigation.

DESIGN

We used an observational multicentre design with telephone interviews.

METHODS

Adult intensive care unit patients (n = 360) were consecutively recruited and interviewed using the intensive care unit-Memory Tool one week after intensive care unit. Interviews were repeated after two and six months and supplemented with Short Form-36 and the Barthel Index.

RESULTS

Delirium was detected in 60% of the patients in our study, and delirious patients had significantly fewer factual memories and more memories of delusion than nondelirious patients up to six months postintensive care unit discharge. Delirium, memories and intensive care unit diaries with follow-up did not affect health-related quality of life and healthcare dependency. Memories of delusions might have an impact on patients assessed as nondelirious.

CONCLUSIONS

More than half of the patients in intensive care unit experience delirium, which is associated with fewer factual memories and more memories of delusions. Short Form-36 might not be sensitive to delirium-related outcomes. Future research should include the development of better assessment tools to determine the long-term consequences of intensive care unit delirium.

RELEVANCE TO CLINICAL PRACTICE

We recommend regular assessment to prevent, detect and treat delirium. We also recommend an intensive care unit follow-up programme providing an opportunity for postintensive care unit patients, particularly previously delirious patients, to discuss their memories and experiences with intensive care unit professionals.

Outcome of ICU survivors: a comprehensive review. The role of patient-reported outcome studies

Problems survivors face after intensive care unit (ICU) discharge begin while they are still in the ward, where many of their specific problems may run unrecognized, but they assume a heavy weight when they arrive at their homes and face several kind of limitations, from being unable to climb stairs because of weight loss, asthenia, dyspnea or joint stiffness to anxiety, depression or post-traumatic stress disorder. Follow-up consultations have given us a better understanding of these specific problems, and the information gained has been used to improve intensive care itself and promote a quality service for patients and relatives. The aim of this article is to provide an overview on adult ICU outcome studies and discuss how they have influenced and improved the delivery of intensive care. We will explain how we went from real patients to outcome studies and what we have learned concerning the consequences of critical illness and critical care. Development of outcome studies, what we have learned through them and our own experience will be outlined focusing mainly in four topics: mortality, physical disability, neuropsychological disability and health-related quality of life. Interventions to improve outcome on these main topics will be presented, and we will explain how we went from outcome studies to clinical interventions, focusing on the most recent proposals of intervention to improve outcome.

Re-building life after ICU: a qualitative study of the patients' perspective

OBJECTIVE

To explore former ICU patients' views on what the key components of a post ICU rehabilitation programme should be.

RESEARCH METHODOLOGY

Thirty five participants completed an online questionnaire accessed via a link to the study from two support groups' websites. Adults (>18 years) who had been patients in ICU were invited to take part. Participants were asked open questions about their ICU experience and their views on ICU rehabilitation. Participants were: aged from 22 to 70 years; from the USA (22), the UK (8), Canada (2), Australia (1) and other (2); 30 female and five male. Findings were analysed using a thematic approach.

FINDINGS

Three themes were identified: 'Information and education', 'Personal support' and 'Assessment and therapy'. Analysis suggested that for participants the aspects of rehabilitation covered by each of the themes were of equal importance.

CONCLUSION

Healthcare professionals in ICU, acute ward and community settings need to be aware of the broad array of physical and psychological challenges faced by patients who have been critically ill. Healthcare professionals need to ensure a holistic approach is implemented to coordinate and facilitate rehabilitation, to address identified patients' needs.

Health-related quality of life in Australian survivors of critical illness

OBJECTIVE

To document health-related quality of life of an Australian sample of intensive care unit survivors 6 months after intensive care unit discharge and compare this with preadmission health-related quality of life, health-related quality of life of national population norms, and international samples of intensive care unit survivors.

DESIGN

Prospective observational single-center study.

SETTING

Eighteen-bed medical-surgical tertiary intensive care unit of an Australian metropolitan hospital.

PATIENTS

Of the 122 eligible patients, 100 were recruited (intensive care unit length of stay >48 hrs, age >18 yrs, not imminently at risk of death) and the final sample comprised 67 patients, age (median [interquartile range], 61 yrs [49-73 yrs]), 60% male admitted to the intensive care unit for a median [interquartile range] 101 hrs (68-149 hrs). Normative age- and sex-matched Australian Short-Form 36 data from the Australian Bureau of Statistics, selected international cohorts of intensive care unit survivors, and their respective national age-matched normative data were included for comparison.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Sixty-seven participants provided responses to questions rating health-related quality of life (Australian Short-Form 36) at preadmission (on admission to the intensive care unit or through retrospective recall as soon as able) and 6 months after intensive care unit discharge. Ten additional participants were unable to provide study data without proxy input and were excluded from analysis. Participants reported clinically meaningful improvements in bodily pain (p = .001), social functioning (p = .03), role-emotional domains of the Short-Form 36 (p = .04), and mental component summary score (p = .01) at 6 months after intensive care unit discharge, mostly attributable to the patients undergoing cardiac surgery, whereas remaining Short-Form 36 domains showed no difference between preadmission and 6 months (p > .05). Participants reported clinically meaningful decrements in preadmission Short-Form 36 data compared with the Australian normative population with role-physical (p < .001) and physical functioning (p < .001) most affected at follow-up. Health-related quality of life in this sample was comparable with international samples of intensive care unit survivors.

CONCLUSIONS

Although the majority of health-related quality of life domains did not differ between preadmission and 6-month follow-up, participants reported significant and clinically meaningful improvements in pain and mental health at follow-up. Critical illness survivors' health-related quality of life remained within 1 sd of Australian norms at follow-up and physical function health-related quality of life was most affected. Health-related quality of life in these Australian survivors of the intensive care unit was comparable with international survivors 6 months after intensive care unit admission.

Long-term survival after surgical intensive care unit admission: fifty percent die within 10 years

OBJECTIVE

Treatment of surgical patients in intensive care unit (ICU) comes along with major disadvantages, which have to be justified by some acceptable short- and long-term outcomes. Short-term effects of treatment in ICU have been well-documented. The aims of this study were to quantify the long-term survival of more than 10 years' follow-up of a large cohort of patients admitted to a surgical ICU and to investigate the effects of age, gender, and underlying disease on this long-term survival.

PATIENTS/METHODS

Of all surgical patients admitted to the ICU of the St Elisabeth Hospital between 1995 and 2000, patient characteristics, disease category, APACHE II score, and survival were prospectively registered. A follow-up with a mean of 8 years after discharge was achieved. The independent association of multiple covariates was done using cox proportional hazard analysis.

RESULTS

Of the 1822 patients included, 936 (51%) had died within 11 years and 52 patients were lost to follow-up. Overall ICU and in-hospital mortality were 11% and 16%, respectively. Age, gender, APACHE II score, the need for dialysis, and surgical classification were independently associated with long-term survival. Mortality increased with age of admittance to the ICU (hazard ratio, 1.058), whereas female patients had a lower chance to die (hazard ratio, 0.793). However, the preadmission disease did not influence long-term outcome. Long-term mortality rates in various surgical classification groups varied between 29% for trauma and 80% for gastrointestinal patients. In gastrointestinal, oncological, general surgical, and/or high-aged patients, a negative effect on mortality persisted beyond 5 years. The mortality ratio was increased twofold in comparison to the general population (51% vs 27%).

CONCLUSION

Ten years after ICU discharge, survival was only 50%. After ICU treatment, survival follows distinct patterns in which age, gender, surgical classification, the need of dialysis, and APACHE II score are independent determinants, and long lasting.

Social integration: an important factor for health-related quality of life after critical illness

OBJECTIVES

To examine to what extent availability of social integration affects health-related quality of life (HRQoL) in former intensive care unit (ICU) patients and how it relates to corresponding findings in a general reference group.

DESIGN

Controlled, multicenter, prospective, explorative study.

SETTING AND PATIENTS

HRQoL data (SF-36) were collected from three combined medical and surgical ICUs in the south-east of Sweden. Social integration was assessed by the Availability of Social Integration (AVSI) instrument (seven questions related to the social interaction of the patient). As reference group, a random sample (n = 6,093) of people from the uptake area of the hospitals was used. Social integration (AVSI), HRQoL (SF-36), and comorbidity were examined also in the reference group.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

The level of social integration significantly affected HRQoL for the former ICU patients, whereas no such effect was seen for the general reference group. For the ICU patients, social integration affected HRQoL to a larger extent than age, sex, and the ICU-related factors examined, but to a lower extent than the pre-existing diseases.

CONCLUSIONS

For a comprehensive assessment of HRQoL in former ICU patients, it is mandatory to include the effect of social integration.

Critical care nurses' experiences of follow-up visits to an ICU

AIM

The aim of this study was to describe critical care nurses' experiences of follow-up visits for formerly critically ill people discharged from an intensive care unit and their close relatives.

BACKGROUND

The critical illness experience affects the ill person and their close relatives not only during the stay in an intensive care unit, but also for a long time afterwards. Follow-up visits were introduced to offer people the opportunity to talk about their experiences. This activity has not been studied earlier from the perspective of critical care nurses.

DESIGN

The design of this study was qualitative.

METHOD

Eight critical care nurses narrated their experiences of follow-up visits by formerly critically ill people and their close relatives to an intensive care unit. Data were collected during 2007-2008. Qualitative thematic content analysis was applied to the interview texts.

RESULTS

The findings show that to feel they were doing a good job it was vital for the critical care nurses to be well prepared for the follow-up visits. It was difficult, in a positive way, to recognise formerly critically ill people when they returned looking healthy. The critical care nurses were disappointed that their former patients remembered so few real events. The follow-up visits gave the critical care nurses a new picture of how the critically illness experience influenced the former patient's everyday life during and after their stay in the intensive care unit and how it affected the lives of their close relatives.

CONCLUSIONS

Through sharing the experiences of formerly critically ill peoples' and their close relatives' critical care nurses receive valuable feedback about their work.

RELEVANCE TO CLINICAL PRACTICE

Receiving feedback about one's work from follow-up visits gives critical care nurses the possibility for to evaluate given care. Follow-up visits to intensive care units can provide them with valuable knowledge that might lead to improved nursing care.

Healthcare Utilisation among Patients Discharged from Hospital after Intensive Care

Surviving critical illness can be life-changing and presents new healthcare challenges for patients after hospital discharge. This feasibility study aimed to examine healthcare service utilisation for patients discharged from hospital after intensive care unit stay. Following Ethics Committee approval, patients aged 18 years and older were recruited over three months. Those admitted after cardiac surgery, discharged to another facility or against medical advice were excluded. Patients were informed of the study by post and followed-up by telephone at two and six months after discharge. General practitioners were also contacted (44% responded). Among 187 patients discharged from hospital, 11 died, 25 declined to participate and 39 could not be contacted. For 112 patients (60%) who completed a survey, the majority (82%) went home from hospital and were cared for by their partner (53%). More than half of the patients (58%) reported taking the same number of medications after intensive care unit stay but 30% took more (P=0.023). While there was no change in the number of visits to the general practitioner for 64% of patients, 29% reported an increase after intensive care unit stay. At six months, 40% of responders who were not retired were unemployed. Discharge summary surveys revealed 39 general practitioners (71%) were satisfied with details of ongoing healthcare needs. Twenty-one general practitioners wrote comments: 10 reported insufficient information about ongoing needs/rehabilitation and two reported no mention of intensive care unit stay. Survivors of critical illness had increased healthcare needs and despite most returning home, had a low workforce participation rate. This requires further investigation to maximise the benefits of survival from critical illness.

[Treatment of serious burns]

BACKGROUND

Treatment of patients with large burns is challenging.

MATERIAL AND METHOD

The article is based on clinical experience, and a non-systematic review in PubMed.

RESULTS

In patients with burns covering more than 10 - 15 % of the total body surface area, fluid resuscitation should be initiated early. Fluid induces edema, and facial burns may necessitate early orotracheal intubation to secure the airways. Reduced ventilation and-/or peripheral circulation due to deep burns should be managed by early escharotomy (and, more seldom, fasciotomy) at the primary hospital. Respiratory distress is most often due to vigorous fluid resuscitation, secretions, pneumonia and-/or sepsis. Fiber bronchoscopy may reveal inhalation injury and enables removal of secreted material from the airways. In the acute initial phase, hypotension is usually caused by hypovolemia. Subsequently a massive inflammatory response (SIRS) causes vasodilatation, hypotension and increased cardiac output. Wound and airway infections are common. SIRS may cause CRP levels above 100 and a body temperature of 38 - 39 degrees C, which makes it difficult to find the right time to start antibiotic treatment. Nevertheless, prophylactic use of antibiotics is not encouraged. Definitive surgery, excision and transplantation, should be performed early, preferably within the first week.

INTERPRETATION

Patients with large burns should be treated according to general principles for intensive medical care, preferably in units with special experience in treatment of burns.

[Outcome after intensive care]

BACKGROUND

Intensive care is medical care for critically ill patients. Over the last 20 years more attention has been drawn to studying long-term outcome after intensive care.

MATERIAL AND METHODS

This article is based on data from the authors' systematic follow up of ICU (intensive care unit) patients and literature identified through non-systematic searches in PubMed.

RESULTS

In Norway more than 80 % of ICU patients survive the hospital stay. From about two years after intensive care and onwards, the overall survival rate parallels that of the total population. Pre-admission data show that ICU patients in general have more co-morbidity and reduction of life quality and functional status than the normal population. Their quality of life increases with time, and most patients become independent of others.

INTERPRETATION

Many ICU patients have rehabilitation potential despite critical illness and comorbidity and most of the long-term survivors achieve acceptable quality of life. ICU patients are a heterogeneous group with great variation in short and long-term outcome. Organization of intensive care should include follow-up after hospital discharge.

Patients' memory and psychological distress after ICU stay compared with expectations of the relatives

PURPOSE

To compare patients' psychological distress and memories from intensive care unit (ICU) treatment 4-6 weeks after ICU discharge with expectations of their relatives. Further, to explore the relationship between personality traits and ICU memories with psychological distress.

METHODS

A cross-sectional study of 255 patients and 298 relatives. The questionnaire included: hospital anxiety and depression scale (HADS), impact of event scale (IES), life orientation test, ICU memory tool and memory of ICU; technical procedures, pain, lack of control and inability to express needs. Relatives were assessed for their expectations of the patients' memories and psychological distress.

RESULTS

Twenty-five percent of the patients reported severe posttraumatic stress symptoms, IES-total >or= 35. The levels of anxiety and depression were significantly higher than in the general population, mean anxiety was 5.6 versus 4.2 (p < 0.001), and mean depression was 4.8 versus 3.5 (p < 0.001). Relatives expected more psychological distress and the relatives thought the patient was less able to express needs than the patients reported (p < 0.001). Higher age, unemployment, respirator treatment, pessimism, memory of pain, lack of control and inability to express needs were independent predictors of posttraumatic stress symptoms (p < 0.01).

CONCLUSIONS

Psychological distress symptoms were frequent among ICU survivors. Relatives expected the patients to be more distressed after ICU treatment than the patients reported. The strongest predictors of posttraumatic stress symptoms from the ICU were memoris about pain, lack of control and inability to express needs. Pessimism may be a reason for psychological distress and should be addressed during follow up, as pessimistic patients may need more motivation and support.

Evaluation of the effect of prospective patient diaries on emotional well-being in intensive care unit survivors: a randomized controlled trial

OBJECTIVE

To evaluate the effect of a prospective diary intervention on levels of anxiety and depression in a group of intensive care unit survivors.

DESIGN

Pragmatic randomized controlled trial.

SETTING

Adult intensive care unit, medical/surgical wards of a district general hospital and community bases.

PATIENTS

A total of 36 patients who were admitted to the intensive care unit between March 2006 and March 2007 for a minimum of 48 hrs.

INTERVENTIONS

Prospective diary kept by nursing staff for the duration of the patient's stay on intensive care unit, containing daily information about their physical condition, procedures and treatments, events occurring on the unit, and significant events from outside the unit.

MEASUREMENT AND MAIN RESULTS

At initial assessment, almost half of patients fell into the "disorder likely" category on the Hospital Anxiety and Depression Scale (44% for anxiety and 47.2% for depression). Paired-samples Student's t tests to compare the Hospital Anxiety and Depression Scale scores at time 1 and time 2 in the two participant groups revealed that the experimental group displayed statistically significant decreases in both anxiety (t (1,17) = 2.65, p < 0.05) and depression (t (1,17) = 3.33, p < 0.005) scores, while the control group did not, a difference attributed to the diary intervention.

CONCLUSIONS

Survivors of critical illnesses are likely to experience clinically significant symptoms of anxiety and depression following their discharge from hospital. The prospective diary intervention designed to help patients understand what happened to them in intensive care and it has a significant positive impact on anxiety and depression scores almost 2 months after patients' discharge from intensive care unit. Attempts to replicate these results using larger samples are therefore encouraged, with the aim of informing best practice guidelines.

[Changes in health-related quality of life after ICU according to diagnostic category. Comparison of two measurement instruments]

OBJECTIVE

Assessment of health related quality of life (HRQOL) before and 12 months after discharge from a mixed intensive care unit (ICU) according to diagnostic category and the relationship between both instruments.

DESIGN

Prospective observational study.

SETTING

The combined medical/surgical ICU in a secondary university hospital with 450 beds.

PATIENTS

Patients admitted to the ICU over an 18-month period.

MAIN VARIABLES

Variables on demography, diagnosis on admission, severity of acute illness score (APACHE II), length of stay, procedures, mortality and the HRQOL were collected using the Short Form SF-36 and EQ-5D questionnaires. Health status prior to admission was evaluated retrospectively.

RESULTS

Both questionnaires were answered by 189 patients. A significant deterioration in the quality of life was observed 12 months after ICU discharge. Head injury and neurological patients had worse HRQOL one year after discharge. Multiple trauma patients presented severe physical limitations and pain, but without significant differences on the emotional level. The EQ Visual Analogue Scale and the EQ Index score showed clinically relevant differences in these three groups. Respiratory patients are the only group in whom the HRQOL improved. Comparison between both measurement instruments showed a strong correlation on the physical functioning level, but a weaker correlation on the emotional functioning one.

CONCLUSIONS

HRQOL assessment of ICU patients must be done according to a diagnostic category. Both instruments (the EQ-5D and SF-36) are capable of detecting changes in HRQOL. Despite differences in structure and content, both measure similar aspects of quality of life.

Impact of previous sepsis on the accuracy of procalcitonin for the early diagnosis of blood stream infection in critically ill patients

Background

Blood stream infections (BSI) are life-threatening infections in intensive care units (ICU), and prognosis is highly dependent on early detection. Procalcitonin levels have been shown to accurately and quickly distinguish between BSI and noninfectious inflammatory states in critically ill patients. It is, however, unknown to what extent a recent history of sepsis (namely, secondary sepsis) can affect diagnosis of BSI using PCT.

Methods

review of the medical records of every patient with BSI in whom PCT dosage at the onset of sepsis was available between 1^st September, 2006 and 31^st July, 2007.

Results

179 episodes of either primary (n = 117) or secondary (n = 62) sepsis were included. Procalcitonin levels were found to be markedly lower in patients with secondary sepsis than in those without (6.4 [9.5] vs. 55.6 [99.0] ng/mL, respectively; p < 0.001), whereas the SOFA score was similar in the two groups. Although patients in the former group were more likely to have received steroids and effective antibiotic therapy prior to the BSI episode, and despite a higher proportion of candidemia in this group, a low PCT value was found to be independently associated with secondary sepsis (Odd Ratio = 0.33, 95% Confidence Interval: 0.16–0.70; p = 0.004). Additional patients with suspected but unconfirmed sepsis were used as controls (n = 23). Thus, diagnostic accuracy of PCT as assessed by the area under the receiver-operating characteristic curves (AUROCC) measurement was decreased in the patients with secondary sepsis compared to those without (AUROCC = 0.805, 95% CI: 0.699–0.879, vs. 0.934, 95% CI: 0.881–0.970, respectively; p < 0.050).

Conclusion

In a critically ill patient with BSI, PCT elevation and diagnosis accuracy could be lower if sepsis is secondary than in those with a first episode of infection.

Development of the 3-SET 4P questionnaire for evaluating former ICU patients' physical and psychosocial problems over time: a pilot study

BACKGROUND

Current studies reveal a lack of consensus for the evaluation of physical and psychosocial problems after ICU stay and their changes over time.

OBJECTIVES

The aim was to develop and evaluate the validity and reliability of a questionnaire for assessing physical and psychosocial problems over time for patients following ICU recovery.

PATIENTS

Thirty-nine patients completed the questionnaire, 17 were retested.

METHODS AND RESULTS

The questionnaire was constructed in three sets: physical problems, psychosocial problems and follow-up care. Face and content validity were tested by nurses, researchers and patients. The questionnaire showed good construct validity in all three sets and had strong factor loadings (explained variance >70%, factor loadings >0.5) for all three sets. There was good concurrent validity compared with the SF 12 (r(s)>0.5). Internal consistency was shown to be reliable (Cronbach's alpha 0.70-0.85). Stability reliability on retesting was good for the physical and psychosocial sets (r(s)>0.5).

CONCLUSION

The 3-set 4P questionnaire was a first step in developing an instrument for assessment of former ICU patients' problems over time. The sample size was small and thus, further studies are needed to confirm these findings.

Quantification of lean and fat tissue repletion following critical illness: a case report

INTRODUCTION

Muscle wasting is a recognised feature of critical illness and has obvious implications for patient rehabilitation and recovery. Whilst many clinicians believe lean tissue repletion to be a slow process following critical illness, and a probable explanation for poor functional recovery of patients many months after resolution of the illness, we have found no studies quantifying body composition changes during patient recovery.

METHODS

A combination of assessment techniques were used to monitor changes in body composition (that is, fat, water, protein and mineral), following intensive care unit (ICU) discharge, in a 38-year-old female recovering from extrapontine myelinolysis. Assessments were made at discharge from the ICU and then again 1 month, 3 months, 6 months and 12 months later. Functional recovery (respiratory muscle and hand-grip strength) and quality of life (36-item Short-form Health Survey) were assessed at these same timepoints.

RESULTS

Twelve months after discharge from the ICU, and despite an extensive rehabilitation programme and improvements in respiratory muscle and hand-grip muscle strength, our patient was unable to return to full-time employment and continued to complain of fatigue. She had successfully regained weight and was back to her pre-illness body weight. Body composition measurements showed that an incredible 73% of the weight gained was due to an increase in body fat.

CONCLUSION

It is difficult to extrapolate the results of a single case to the wider ICU population, not least because the present patient sustained a significant neurological injury, but our data are the first to support the long-held belief that patient weight gain following critical illness is largely attributable to a gain in fat mass. The magnitude of body composition changes in the present patient are startling and support the need for longitudinal body composition data in a wider ICU population.

Multiple organ failure after trauma affects even long-term survival and functional status

BACKGROUND

The aim of this study was to assess the incidence of organ failure in trauma patients treated in an intensive care unit (ICU), and to study the relationship between organ failure and long-term survival and functional status.

METHODS

This is a cohort study of all adult ICU trauma patients admitted to a university hospital during 1998 to 2003. Organ failure was quantified by the Sequential Organ Failure Assessment (SOFA) score. A telephone interview was conducted in 2005 (2 to 7 years after trauma) using the Karnofsky Index to measure functional status, and the Glasgow Outcome Score to measure recovery.

RESULTS

Of the 322 patients included, 47% had multiple organ failure (MOF), and 28% had single organ failure. In a Cox regression, MOF increased the overall risk of death 6.0 times. At follow-up, 242 patients (75%) were still alive. Patients with MOF had 3.9 times greater odds for requiring personal assistance in activities of daily living compared to patients without organ failure. Long-term survival and functional status were the same for patients suffering single organ failure and no organ failure. Complete recovery occurred in 52% of survivors, and 87% were able to look after themselves.

CONCLUSION

Almost half of the ICU trauma patients had MOF. While single organ failure had no impact on long-term outcomes, the presence of MOF greatly increased mortality and the risk of impaired functional status. MOF expressed by SOFA score may be used to define trauma patients at particular risk for poor long-term outcomes.

A qualitative study exploring patients perceived quality of life following an emergency liver transplant for acute liver failure

Liver transplantation is now an accepted and successful therapy for both acute and chronic liver diseases. Whilst the study of health related quality of life (HRQoL) post-transplantation for chronic liver disease (CLD) has been well documented, there is little data measuring HRQoL following liver transplantation for acute liver failure (ALF), despite super urgent transplantation constituting 16.6% of all United Kingdom liver transplantation. Therefore, the aim of the present study was to document the HRQoL in patients who have received an emergency liver transplant for ALF. Data collection employed between method triangulation, using the Short Form 36 quality of life health questionnaire for both ALF (n=47) and CLD (n=49), and six semi-structured interviews. Only the qualitative element of the study is reported here. Phenomenological analysis of the semi-structured interviews identified four themes relating to the physical changes encountered (inactivity), physical recovery (health transition); changes made to the transplant recipients life styles (modification); and outlook. The majority of transplanted ALF transplant recipients' stated that they have a good quality of life, which was often comparable to their pretransplantation lifestyle. However, the initial recovery process was often difficult and was related to the physical changes instigated from their multi-organ failure and intensive care stay, which can present numerous physical and emotional challenges.

Alteraciones emocionales y necesidades psicológicas de pacientes en una Unidad de Cuidados Intensivos

From the time when a disease whose treatment is going to require hospitalization for a surgical intervention is diagnosed, both the patient and his/her family members or primary caretakers are involved in a process that may involve the experience of several emotional alterations. This work focuses on the description of the different psychological problems and needs manifested by the patients who require, as part of the treatment process and recovery control, admission to an Intensive Care Unit (ICU). During the patient's stay in the ICU, the emotional alterations mentioned most frequently by them are anxiety, stress, depression or the so-called intensive care syndrome, during which factors such as excessive noise that may make sleeping and rest difficult, pain, the methods used for ventilation that prevent the patients from communicating adequately, etc. Furthermore, the patients generally develop a feeling of loss of self-control, the main needs described being the sensation of safety and "knowing what is happening". The experiences lived may continue to produce emotional alterations even months after hospital discharge, with the development of a Posttraumatic Stress Disorder. This justifies a follow-up in order to detect them and treat them adequately. It seems to be appropriate for the treatment of these patients to be multidisciplinary, attending to both the physical needs related with the disease as well as the psychological ones.

Factual memories of ICU: recall at two years post-discharge and comparison with delirium status during ICU admission - a multicentre cohort study

AIMS AND OBJECTIVE

To examine the relationship between observed delirium in ICU and patients' recall of factual events up to two years after discharge.

BACKGROUND

People, the environment, and procedures are frequently cited memories of actual events encountered in ICU. These are often perceived as stressors to the patients and the presence of several such stressors has been associated with the development of reduced health-related quality of life or post-traumatic stress syndrome.

DESIGN

Prospective cohort study using interview technique.

METHOD

The cohort was assembled from 152 patients who participated in a previously conducted multi-centre study of delirium incidence in Australian ICUs. The interviews involved a mixture of closed- and open-ended questions. Qualitative responses regarding factual memories were analysed using thematic analysis. A five-point Likert scale with answers from 'always' to 'never' was used to ask about current experiences of dream, anxiety, sleep problems, fears, irritability and/or mood swings. Scoring ranged from 6 to 30 with a mid-point value of 18 indicating a threshold value for the diagnosis of post-traumatic stress syndrome. A P-value of <0.05 was considered significant for all analyses.

RESULTS

Forty-one (40%) out of 103 potential participants consented to take part in the follow-up interview; 18 patients (44%) had been delirious and 23 patients (56%) non-delirious during the ICU admission. The non-participants (n = 62) formed a control group to ensure a representative sample; 83% (n = 34) reported factual memories either with or without recall of dreaming. Factual memories were significantly less common (66% cf. 96%) in delirious patients (OR 0.09, 95%CI 0.01-0.85, p = 0.035). Five topics emerged from the thematic analysis: 'procedures', 'staff', 'comfort', 'visitors', and 'events'. Based on the current experiences, five patients (12%, four non-delirious and one delirious) scored > or =18 indicative of symptoms of post-traumatic stress syndrome; this did not reach statistical significance. Memory of transfer out of ICU was less frequent among the delirious patients (56%, n = 10) than among the non-delirious patients (87%, n = 20) (p = 0.036).

CONCLUSION

Most patients have factual memories of their ICU stay. However, delirious patients had significantly less factual recall than non-delirious patients. Adverse psychological sequelae expressed as post-traumatic stress syndrome was uncommon in our study. Every attempt must be made to ensure that the ICU environment is as hospitable as possible to decrease the stress of critical illness. Post-ICU follow-up should include filling in the 'missing gaps', particularly for delirious patients. Ongoing explanations and a caring environment may assist the patient in making a complete recovery both physically and mentally.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the need for continued patient information, re-assurance and optimized comfort. While health care professionals cannot remove the stressors of the ICU treatments, we must minimize the impact of the stay. It must be remembered that most patients are aware of their surroundings while they are in the ICU and it should, therefore, be part of ICU education to include issues regarding all aspects of patient care in this particularly vulnerable subset of patients to optimize their feelings of security, comfort and self-respect.

Post-ICU consequences of patient wakefulness and sedative exposure during mechanical ventilation

OBJECTIVE

To determine the relationship between measures of critical illness (sedative/analgesic administration, wakefulness and organ dysfunction), intensive care unit (ICU) recall and symptoms of posttraumatic stress disorder.

DESIGN

Prospective, observational study with post-ICU follow-up.

SETTING

Medical and surgical ICUs at a teaching hospital.

PATIENTS

Two hundred seventy-seven subjects requiring >36h of mechanical ventilation were enrolled; 149 completed follow-up interviews 2 months later and 80 at 6 months.

INTERVENTIONS

None.

RESULTS

ICU recall was greater for events occurring at the end of critical illness; however, 18% of subjects had amnesia for the entire ICU course. Factual ICU recall was weakly associated with increased wakefulness during mechanical ventilation (r2=0.03-0.11, p<0.05). Posttraumatic stress disorder prevalence was 17% at 2 months and 15% at 6 months. The avoidance-numbing cluster had the highest specificity (91%) for a formal diagnosis and the re-experiencing cluster had the lowest (69%). Recall of a delirious memory during critical illness was associated with more severe posttraumatic stress symptoms, but there was no association between posttraumatic stress symptoms and factual recall of ICU events. Neither ICU recall nor posttraumatic stress symptoms were associated with the intensity of sedative administration during mechanical ventilation. Posttraumatic stress symptoms were lowest in patients either the most awake during mechanical ventilation or the least awake.

CONCLUSION

Wakefulness during mechanical ventilation has a greater influence on post-ICU recall and posttraumatic stress symptoms than sedative drug exposure or severity of illness. It is difficult to predict the future psychological consequences of an individual patient's critical illness.