The Pathophysiology of Long-term Neuromuscular and Cognitive Outcomes Following Critical Illness

Early mobilisation in patients with shock and receiving vasoactive drugs in the intensive care unit: A systematic review and meta-analysis of observational studies

OBJECTIVE

The aim of the study was to assess the feasibility and safety of early mobilisation in patients with shock requiring vasoactive drugs in the intensive care unit (ICU).

DESIGN

Systematic review and meta-analysis.

SETTING

Intensive care unit (ICU).

PATIENTS OR PARTICIPANTS

Adult patients requiring vasoactive drugs who received early mobilisation in the intensive care unit.

INTERVENTIONS

A systematic search was conducted using the databases PubMed, Cochrane Library, Scopus, Medline Ovid, Science Direct, and CINAHL, including observational studies involving adult patients requiring vasoactive drugs who received early mobilisation. A meta-analysis was performed on the proportion of safety events and the proportion of early mobilisation in patients with high, moderate, and low doses of vasoactive drugs.

MAIN VARIABLES OF INTEREST

Feasibility, safety events, and the maximum level of activity achieved during early mobilisation.

RESULTS

The search yielded 1875 studies, of which 8 were included in the systematic review and 5 in the meta-analysis. The results showed that 64% (95% CI: 34%-95%, p<0.05) of patients were mobilised with low doses of vasoactive drugs, 30% (95% CI: 7%-53%, p<0.05) with moderate doses, and 7% (95% CI: 3%-16%, p 0.17) with high doses. The proportion of adverse events was low, at 2% (95% CI: 1%-4%, p<0.05).

CONCLUSIONS

Early mobilisation in patients with shock and the need for vasoactive drugs is feasible and generally safe. However, there is an emphasis on the need for further high-quality research to confirm these findings.

Characteristics of Mid-Term Post-Intensive Care Syndrome in Patients Attending a Follow-Up Clinic: A Prospective Comparison Between COVID-19 and Non-COVID-19 Survivors

At present, it is not clear if critically ill COVID-19 survivors have different needs in terms of follow-up compared with other critically ill survivors, and thus if duplicated post-ICU trajectories are mandatory.

OBJECTIVES

To compare the post-intensive care syndrome (PICS) of COVID-19 acute respiratory distress syndrome and non-COVID-19 (NC) survivors referred to a follow-up clinic at 3 months (M3) after ICU discharge.

DESIGN SETTING AND PARTICIPANTS

Adults who survived an ICU stay greater than or equal to 7 days and attended the M3 consultation were included in this observational study performed in a post-ICU follow-up clinic of a single tertiary hospital.

MAIN OUTCOMES AND MEASURES

Patients underwent a standardized assessment, addressing health-related quality of life (3-level version of EQ-5D), sleep disorders (Pittsburgh Sleep Quality Index [PSQI]), physical status (Barthel index, handgrip and quadriceps strengths), mental health disorders (Hospital Anxiety and Depression Scale and Impact of Event Scale-Revised [IES-R]), and cognitive impairment (Montreal Cognitive Assessment [MoCA]).

RESULTS

A total of 143 survivors (86 COVID and 57 NC) attended the M3 consultation. Their median age and severity scores were similar. NC patients had a shorter ICU stay (10 d [8-17.2 d]) compared with COVID group (18 d [10.8-30 d]) (p = 0.001). M3 outcomes were similar in the two groups, except for a higher PSQI (p = 0.038) in the COVID group (6 [3-9.5]) versus NC group (4 [2-7]), and a slightly lower Barthel index in the NC group (100 [100-100]) than in the COVID group (100 [85-100]) (p = 0.026). However, the proportion of patients with abnormal values at each score was similar in the two groups. Health-related quality of life was similar in the two groups. The three MoCA (≥ 26), IES-R (<33), and Barthel (=100) were normal in 58 of 143 patients (40.6%). In contrast, 68.5% (98/143) had not returned to their baseline level of daily activities.

CONCLUSIONS AND RELEVANCE

In our follow-up clinic at 3 months after discharge, the proportion of patients presenting alterations in the main PICS domains was similar whether they survived a COVID-19 or another critical illness, despite longer ICU stay in COVID group. Cognition and sleep were the two most affected PICS domains.

Effectiveness of physical rehabilitation interventions in critically ill patients-A protocol for an overview of systematic reviews

INTRODUCTION

Adult and pediatric patients admitted to intensive care units (ICUs) requiring invasive ventilatory support, sedation, and muscle blockade may present neuromusculoskeletal deterioration. Different physical rehabilitation interventions have been studied to evaluate their effectiveness in improving critically ill patients' outcomes. Given that many published systematic reviews (SRs) aims to determine the effectiveness of different types of physical rehabilitation interventions, it is necessary to group them systematically and assess the methodological quality of SRs to help clinicians make better evidence-based decisions. This overview of SRs (OoSRs) aims to map the existing evidence and to determine the effectiveness of physical rehabilitation interventions to improve neuromusculoskeletal function and other clinical outcomes in adult and pediatric critically ill patients.

METHODS

An OoSRs of randomized and non-randomized clinical trials involving critically ill adult and pediatric patients receiving physical rehabilitation intervention will be conducted. A sensitive search of MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Cochrane Library, Epistemonikos, and other search resources will be conducted. Two independent reviewers will conduct study selection, data extraction, and methodological quality assessment. Discrepancies will be resolved by consensus or a third reviewer. The degree of overlap of studies will be calculated using the corrected covered area. The methodological quality of the SRs will be measured using the AMSTAR-2 tool. The GRADE framework will report the certainty of evidence by selecting the "best" SR for each physical rehabilitation intervention and outcome.

DISCUSSION

The findings of this overview are expected to determine the effectiveness and safety of physical rehabilitation interventions to improve neuromusculoskeletal function in adult and pediatric critically ill patients based on a wide selection of the best available evidence and to determine the knowledge gaps in this topic by mapping and assessing the methodological quality of published SRs.

REGISTRATION NUMBER

CRD42023389672.

Survival and Health Care Costs with IMV vs. NIV in Dementia Patients Admitted with Pneumonia and Respiratory Failure

RATIONALE

Invasive mechanical ventilation (IMV) may be burdensome for persons with advanced dementia. Research has found that IMV use in persons with dementia has increased in the US, Spain, and Canada.

OBJECTIVES

Compare the outcomes and health care costs among hospitalized advanced dementia patients treated with non-invasive ventilation (NIV) versus IMV.

METHODS

Retrospective cohort study of hospitalized patients aged 66 and older with pneumonia, or septicemia with pneumonia, treated either with NIV or IMV between 2015 and 2017. Persons were included if they had a Minimum Data Set (MDS) assessment between 1 and 120 days prior to hospitalization indicating the person had advanced dementia with 4+ impairments in the Activities of Daily Living. Propensity matched analysis was performed using clinical information from the MDS, measures of Chronic Condition Warehouse (CCW) chronic disease indicators, and prior utilization measures. Main outcome measures were survival and health care costs up to one year post discharge.

RESULTS

Among the 27,483 hospitalizations between 2015 and 2017, 12.5% were treated with IMV and 8.2% received NIV. A propensity matched model comparing IMV to NIV with clinical data from the MDS, CCW indicators of chronic diseases, and prior utilization found matches for 96.3% of hospitalizations with the use of IMV. NIV matched cases had a higher 30-day mortality rate compared to IMV cases (58.7% vs 51.9%, p<=.001) but this survival benefit did not persist, as one-year mortality was slightly higher among IMV compared to NIV (86.5% vs 85.9%, p>.05). One-year health care costs after matching were higher among those treated with IMV compared to NIV (mean $57,122 vs. $33,696, p<.001).

CONCLUSIONS

Among advanced dementia patients hospitalized with pneumonia or septicemia with pneumonia, improvement in 30-day survival for those treated with IMV compared to NIV must be weighed against lack of one-year survival benefit and substantially higher costs.

Changing the Perceptions of a Culture of Safety for the Patient and the Caregiver: Integrating Improvement Initiatives to Create Sustainable Change

Evidence indicates that chances for a successful patient mobility program, prevention of pressure injury and falls, and safe patient handling are enhanced when an organization possesses an appropriate culture for safety. Frequently, these improvement initiatives are managed within silos often creating a solution for one and a problem for the others. A model of prevention integrating early patient mobility, preventing pressure injuries and falls while ensuring caregiver safety, is introduced. The journey begins by understanding why early mobility and safe patient handling are critical to improving overall patient outcomes. Measuring current culture and understanding the gaps in practice as well as strategies for overcoming some of the major challenges for success in each of these areas will result in sustainable change.

Diaphragmatic ultrasonography for predicting ventilator weaning: A meta-analysis

BACKGROUND

Weaning failure is common in mechanically ventilated patients. Whether ultrasound can predict weaning outcome remains controversial. This meta-analysis was performed to assess the accuracy of diaphragmatic ultrasonography for predicting reintubation within 48 hours of extubation.

METHODS

Literature search was performed in PubMed, Embase, and Cochrane Library to identify all the relevant papers, published in English up to July 16, 2017. Eligible studies were included if data were in adequate details to rebuild 2 × 2 contingency tables. Methodological quality of the included studies was evaluated using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) in Review Manager 5.3. The sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and summary receiver operating characteristic (SROC) curve were pooled using the fixed or random effects model, meanwhile, the heterogeneity was evaluated using Cochran Q test and I statistics in Meta-DiSc 1.4. Publication bias was assessed using Deeks funnel plot in Stata 12.0.

RESULTS

Thirteen studies with 742 subjects were included in this meta-analysis. The pooled sensitivities for diaphragm excursion (DE) and diaphragm thickness fraction (DTF) were 0.786 and 0.893, and the pooled specificities were 0.711 and 0.796, respectively. The area under curve (AUC) for DE and DTF were 0.8590 and 0.8381. The DORs for DE and DTF were 10.623 and 32.521. No publication bias was observed among these studies.

CONCLUSIONS

Diaphragmatic ultrasonography is a promising tool for predicting reintubation within 48 hours of extubation. However, due to heterogeneities among the included studies, large-scale studies are warranted to confirm our findings.

Using M-mode ultrasonography to assess diaphragm dysfunction and predict the success of mechanical ventilation weaning in elderly patients

Background

Ultrasonography (US) is a non-invasive and commonly available bedside diagnostic tool. The aim of this study was to assess the utility of M-mode US on ventilator weaning outcomes in elderly patients.

Methods

This was a single center, prospective, observational study in patients aged 80 years or older who were in the medical intensive care unit, had undergone mechanical ventilation for >48 hours, and met the criteria for a spontaneous breathing trial (SBT). For 30 minutes at the start of SBT, each hemi-diaphragmatic movement and the velocity of contraction were evaluated by M-mode US. The the area under the receiver operating characteristic curve (AUROC) was calculated to determine the ability for measured variables to predict successful ventilator weaning.

Results

Forty patients were enrolled and assessed, grouped by those who had US-diagnosed diaphragm dysfunction (DD; 30/40; 75%) and those who did not (10/40; 25%). Patients with DD had a significantly longer total mechanical ventilation duration (536.4±377.05 vs. 250±109.02 hours, P=0.02) and weaning time (425.9±268.31 vs. 216.0±134.22 hours, P=0.002) than patients without DD. Patients with DD also had a higher incidence of weaning failure than patients without DD (24/30 vs. 4/10, P=0.017). Analysis of the receiver operating characteristic (ROC) curve (ROC) curve showed that the optimal cut-off values to predict weaning success were >10.7 mm for the right diaphragmatic movement, and >21.32 mm/s for the right diaphragmatic velocity of contraction; AUROC were 0.839 (95% CI, 0.689-0.936) and 0.833 (95% CI, 0.682-0.932), respectively. The sensitivity, specificity, positive and negative likelihood ratios for predicting weaning success were 83.33% vs. 66.67%, 75.00% vs. 92.86%, 3.33 vs. 9.33, and 0.22 vs. 0.36, for right diaphragmatic movement and diaphragmatic contraction velocity, respectively.

Conclusions

When assessed by M-mode US, DD appeared to be common in ventilated patients aged 80 years or older and was associated with a higher incidence of weaning failure. Larger right diaphragmatic movements or faster right diaphragmatic contraction velocity appeared to be good predictors of mechanical ventilation weaning success in elderly patients.

Short-Term Health-Related Quality of Life of Critically Ill Children Following Daily Sedation Interruption

OBJECTIVE

Our earlier pediatric daily sedation interruption trial showed that daily sedation interruption in addition to protocolized sedation in critically ill children does not reduce duration of mechanical ventilation, length of stay, or amounts of sedative drugs administered when compared with protocolized sedation only, but undersedation was more frequent in the daily sedation interruption + protocolized sedation group. We now report the preplanned analysis comparing short-term health-related quality of life and posttraumatic stress symptoms between the two groups.

DESIGN

Preplanned prospective part of a randomized controlled trial.

SETTING

Two tertiary medical-surgical PICUs in the Netherlands.

PATIENTS

Critically ill children requiring mechanical ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Eight weeks after a child's discharge from the PICU, health-related quality of life was assessed with the validated Child Health Questionnaire and, only for children above 4 years old, posttraumatic stress was assessed with the Dutch Children's Responses to Trauma Inventory. Additionally, health-related quality of life of all study patients was compared with Dutch normative data. Of the 113 patients from two participating centers in the original study, 96 patients were eligible for follow-up and 64 patients were included (response rate, 67%). No difference was found with respect to health-related quality of life between the two study groups. None of the eight children more than 4 years old showed posttraumatic stress symptoms.

CONCLUSIONS

Daily sedation interruption in addition to protocolized sedation for critically ill children did not seem to have an effect on short-term health-related quality of life. Also in view of the earlier found absence of effect on clinical outcome, we cannot recommend the use of daily sedation interruption + protocolized sedation.

Assessment and predictors of physical functioning post-hospital discharge in survivors of critical illness

Background

Prior studies of physical functioning after critical illness have been mostly limited to survivors of acute respiratory distress syndrome. The purpose of this study was to objectively assess muscle strength and physical functioning in survivors of critical illness from a general ICU and the associations of these measures to health-related quality of life (HRQL), mental health and critical illness variables.

Methods

This was a prospective cohort study of 56 patients admitted to a medical ICU (length of stay ≥4 days) from April 1, 2009, and March 31, 2010. Patients were assessed in clinic at 3 months post-hospital discharge. Muscle strength and physical functioning were measured using hand-held dynamometry and the 6-min walk test. HRQL was assessed using the short-form 36 (SF-36) and EuroQol-5D (EQ-5D) questionnaires.

Results

Three months post-hospital discharge, median age- and sex-matched muscle strength was reduced across all muscle groups. The median 6-min walk distance was 72 % of predicted. Physical functioning was associated with reductions in self-reported HRQL (SF-36, EQ-5D) and increased anxiety. Univariate regression modeling showed that reduced muscle strength and 6-min walk distance were associated with sepsis but not ICU length of stay. Multivariate regression modeling showed that sepsis and corticosteroid use were associated with a reduced 6-min walk distance, but again ICU length of stay was not.

Conclusions

Survivors of critical illness have reduced strength in multiple muscle groups and impaired exercise tolerance impacting both HRQL and mental health. These outcomes were worsened by sepsis and corticosteroid use in the ICU but not ICU length of stay. Interventions to minimizing the burden of sepsis in critically ill patients may improve long-term outcomes.

Jordanian survivors' experiences of recovery from critical illness: a qualitative study

BACKGROUND

Despite the fact that a lot of patients consider their discharge from hospitals as a positive sign of progress towards regained health, many of them start suffering from physical, psychological and social problems after discharge from intensive care units.

AIM

This study aims to describe the experiences of Jordanian survivors of critical illnesses 3 months after discharge from a hospital intensive care unit.

METHODS

A descriptive qualitative approach was used to involve 18 Jordanian patients from two hospitals in a major Jordanian city using open-ended interviews. Interview transcripts were analysed using content analysis method.

RESULTS

Three main themes have emerged from the data: (1) new meaning of life; (2) different perspectives on the meaning of life, and (3) struggle for role identity.

LIMITATION

The sample was chosen from one city in Jordan; longitudinal study might help identify the change in patients' experiences over time.

CONCLUSION

Patients described the discharge from the intensive care unit as a means of rescue from death; they began to value their spiritual and religious rituals. Negative traumatic experiences hindered the patients' recovery process. During recovery, patients struggled to resume their power and role in family.

IMPLICATIONS FOR NURSES AND HEALTH POLICY

This study emphasizes the importance of providing care according to the patient's individual needs, related to their cultural and spiritual milieu; there is a need to develop follow-up services for ICU survivors within a national health policy. Further educational and training programmes in the patient's issues after discharge from hospital are needed. This will definitely help nurses care after this patient group.

Physical therapist-established intensive care unit early mobilization program: quality improvement project for critical care at the University of California San Francisco Medical Center

BACKGROUND

Long-term weakness and disability are common after an intensive care unit (ICU) stay. Usual care in the ICU prevents most patients from receiving preventative early mobilization.

OBJECTIVE

The study objective was to describe a quality improvement project established by a physical therapist at the University of California San Francisco Medical Center from 2009 to 2011. The goal of the program was to reduce patients' ICU length of stay by increasing the number of patients in the ICU receiving physical therapy and decreasing the time from ICU admission to physical therapy initiation.

DESIGN

This study was a 9-month retrospective analysis of a quality improvement project.

METHODS

An interprofessional ICU Early Mobilization Group established and promoted guidelines for mobilizing patients in the ICU. A physical therapist was dedicated to a 16-bed medical-surgical ICU to provide physical therapy to selected patients within 48 hours of ICU admission. Patients receiving early physical therapy intervention in the ICU in 2010 were compared with patients receiving physical therapy under usual care practice in the same ICU in 2009.

RESULTS

From 2009 to 2010, the number of patients receiving physical therapy in the ICU increased from 179 to 294. The median times (interquartile ranges) from ICU admission to physical therapy evaluation were 3 days (9 days) in 2009 and 1 day (2 days) in 2010. The ICU length of stay decreased by 2 days, on average, and the percentage of ambulatory patients discharged to home increased from 55% to 77%.

LIMITATIONS

This study relied upon the retrospective analysis of data from 6 collectors, and the intervention lacked physical therapy coverage for 7 days per week.

CONCLUSIONS

The improvements in outcomes demonstrated the value and feasibility of a physical therapist-led early mobilization program.

[Intensive care unit-acquired weakness in the critically ill : critical illness polyneuropathy and critical illness myopathy]

Intensive care unit-acquired weakness (ICUAW) is a severe complication in critically ill patients which has been increasingly recognized over the last two decades. By definition ICUAW is caused by distinct neuromuscular disorders, namely critical illness polyneuropathy (CIP) and critical illness myopathy (CIM). Both CIP and CIM can affect limb and respiratory muscles and thus complicate weaning from a ventilator, increase the length of stay in the intensive care unit and delay mobilization and physical rehabilitation. It is controversially discussed whether CIP and CIM are distinct entities or whether they just represent different organ manifestations with common pathomechanisms. These basic pathomechanisms, however, are complex and still not completely understood but metabolic, inflammatory and bioenergetic alterations seem to play a crucial role. In this respect several risk factors have recently been revealed: in addition to the administration of glucocorticoids and non-depolarizing muscle relaxants, sepsis and multi-organ failure per se as well as elevated levels of blood glucose and muscular immobilization have been shown to have a profound impact on the occurrence of CIP and CIM. For the diagnosis, careful physical and neurological examinations, electrophysiological testing and in rare cases nerve and muscle biopsies are recommended. Nevertheless, it appears to be difficult to clearly distinguish between CIM and CIP in a clinical setting. At present no specific therapy for these neuromuscular disorders has been established but recent data suggest that in addition to avoidance of risk factors early active mobilization of critically ill patients may be beneficial.

Physical therapy management and patient outcomes following ICU-acquired weakness: a case series

BACKGROUND AND PURPOSE

Individuals with critical illness experience dysfunction of many body systems including the neuromuscular system. Neuromuscular impairments result in a syndrome referred to as intensive care unit (ICU)-acquired weakness, which may lead to difficulty with activities and participation. The purposes of this case series were to (1) describe safety and feasibility of physical intervention in individuals with ICU-acquired weakness mechanically ventilated for at least 7 days and (2) characterize physical therapist management and patient outcomes.

CASE DESCRIPTION

Nineteen patients with ICU-acquired weakness who required mechanical ventilation for at least 7 days were enrolled over a 1-year period.

INTERVENTION

Physical therapy (PT) was provided 5 d/wk for 30 minutes per session.

OUTCOMES

Outcome measures included manual muscle tests and item scores from the Functional Independence Measure. Participants completed 170 PT sessions. Only 20 sessions (12%) were stopped before 30 minutes. Seventeen participants survived to discharge; no PT-related adverse events occurred. At discharge, participants who went home showed a trend toward greater independence and strength than those who were discharged to another level of care. Median total hospital days was 28 for those discharged to home and 22 for those discharged to other level of care.

DISCUSSION

This case series demonstrates safety and feasibility of PT intervention for patients with ICU-acquired weakness requiring mechanical ventilation for at least 7 days. The examination and intervention procedures are described and could be implemented with other similar individuals in the hospital setting. Future studies should investigate frequency and duration of physical intervention, both during hospitalization and postdischarge, and how these factors influence outcomes.

Diaphragm dysfunction assessed by ultrasonography: influence on weaning from mechanical ventilation

OBJECTIVE

To determine the prevalence of diaphragmatic dysfunction diagnosed by M-mode ultrasonography (vertical excursion <10 mm or paradoxic movements) in medical intensive care unit patients and to assess the influence of diaphragmatic dysfunction on weaning outcome.

DESIGN

Prospective, observational study.

SETTING

Twenty-eight-bed medical intensive care unit in a university-affiliated hospital.

PATIENTS

Eighty-eight consecutive patients in the medical intensive care unit who required mechanical ventilation over 48 hrs and met the criteria for a spontaneous breathing trial were assessed. Patients with a history of diaphragmatic or neuromuscular disease or evidence of pneumothorax or pneumomediastinum were excluded.

INTERVENTIONS

During spontaneous breathing trial, each hemidiaphragm was evaluated by M-mode ultrasonography using the liver and spleen as windows with the patient supine. Rapid shallow breathing index was simultaneously calculated at the bedside.

MEASUREMENTS AND MAIN RESULTS

The prevalence of ultrasonographic diaphragmatic dysfunction among the eligible 82 patients was 29% (n = 24). Patients with diaphragmatic dysfunction had longer weaning time (401 [range, 226-612] hrs vs. 90 [range, 24-309] hrs, p < .01) and total ventilation time (576 [range, 374-850] hrs vs. 203 [range, 109-408] hrs, p < .01) than patients without diaphragmatic dysfunction. Patients with diaphragmatic dysfunction also had higher rates of primary (20 of 24 vs. 34 of 58, p < .01) and secondary (ten of 20 vs. ten of 46, p = .01) weaning failures than patients without diaphragmatic dysfunction. The area under the receiver operating characteristics curve of ultrasonographic criteria in predicting weaning failure was similar to that of rapid shallow breathing index.

CONCLUSIONS

Using M-mode ultrasonography, diaphragmatic dysfunction was found in a substantial number of medical intensive care unit patients without histories of diaphragmatic disease. Patients with such diaphragmatic dysfunction showed frequent early and delayed weaning failures. Ultrasonography of the diaphragm may be useful in identifying patients at high risk of difficulty weaning.

Lung function and quality of life in survivors of the acute respiratory distress syndrome (ARDS)

Recent studies have begun to describe the long-term outcomes of acute respiratory distress syndrome (ARDS) survivors. These patients experience a number of physical, mental and psychological morbidities that significantly impair their health-related quality of life (HRQL). The trajectory of pulmonary recovery in survivors of ARDS, as it relates to lung function, structure and health-related quality of life (HRQL), is predictable and often persists years after hospital discharge. True pulmonary parenchymal morbidity is uncommon and when present, persistent restrictive disease is likely related to diaphragmatic weakness with a mild reduction in diffusion capacity (DLCO). Future research should focus on identifying patients at risk for long-term functional limitations and the design of rehabilitation interventions tailored to individual patient needs.

Chronic critical illness: prevalence, profile, and pathophysiology

The syndrome of chronic critical illness has well-documented emotional, social, and financial burdens for individuals, caregivers, and the health care system. The purpose of this article is to provide experienced acute and critical care clinicians with essential information about the prevalence and profile of the chronically critically ill patient needed for comprehensive care. In addition, pathophysiology contributing to chronic critical illness is addressed, though the exact mechanism underlying the conversion of acute critical illness to chronic critical illness is unknown. Clinicians can use this information to identify at-risk intensive care unit patients and to institute proactive care to minimize burden and distress experienced by patients and their caregivers.

Long-term cognitive and psychological outcomes in the awakening and breathing controlled trial

RATIONALE

Studies have shown that reducing sedation of critically ill patients shortens time on the ventilator and in the intensive care unit (ICU). Little is known, however, of how such strategies affect long-term cognitive, psychological, and functional outcomes.

OBJECTIVES

To determine the long-term effects of a wake up and breathe protocol that interrupts and reduces sedative exposure in the ICU.

METHODS

In this a priori planned substudy conducted at one tertiary care hospital during the Awakening and Breathing Controlled Trial, a multicenter randomized controlled trial, we assessed cognitive, psychological, and functional/quality-of-life outcomes 3 and 12 months postdischarge among 180 medical ICU patients randomized to paired daily spontaneous awakening trials with spontaneous breathing trials (SBTs) or to sedation per usual care plus daily SBTs.

MEASUREMENTS AND MAIN RESULTS

Cognitive impairment was less common in the intervention group at 3-month follow-up (absolute risk reduction, 20.2%; 95% confidence interval, 1.5-36.1%; P = 0.03) but not at 12-month follow-up (absolute risk reduction, -1.9%; 95% CI, -21.3 to 27.1%; P = 0.89). Composite cognitive scores, alternatively, were similar in the two groups at 3-month and 12-month follow-up (P = 0.80 and 0.61, respectively), as were symptoms of depression (P = 0.59 and 0.82) and posttraumatic stress disorder (P = 0.59 and 0.97). Activities of daily living, functional status, and mental and physical quality of life were similar between groups throughout follow-up.

CONCLUSIONS

In this trial, management of mechanically ventilated medical ICU patients with a wake up and breathe protocol resulted in similar cognitive, psychological, and functional outcomes among patients tested 3 and 12 months post-ICU. The proven benefits of this protocol, including improved 1-year survival, were not offset by adverse long-term outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT 00097630).

Sepsis-induced myopathy

Sepsis is a major cause of morbidity and mortality in critically ill patients, and despite advances in management, mortality remains high. In survivors, sepsis increases the risk for the development of persistent acquired weakness syndromes affecting both the respiratory muscles and the limb muscles. This acquired weakness results in prolonged duration of mechanical ventilation, difficulty weaning, functional impairment, exercise limitation, and poor health-related quality of life. Abundant evidence indicates that sepsis induces a myopathy characterized by reductions in muscle force-generating capacity, atrophy (loss of muscle mass), and altered bioenergetics. Sepsis elicits derangements at multiple subcellular sites involved in excitation contraction coupling, such as decreasing membrane excitability, injuring sarcolemmal membranes, altering calcium homeostasis due to effects on the sarcoplasmic reticulum, and disrupting contractile protein interactions. Muscle wasting occurs later and results from increased proteolytic degradation as well as decreased protein synthesis. In addition, sepsis produces marked abnormalities in muscle mitochondrial functional capacity and when severe, these alterations correlate with increased death. The mechanisms leading to sepsis-induced changes in skeletal muscle are linked to excessive localized elaboration of proinflammatory cytokines, marked increases in free-radical generation, and activation of proteolytic pathways that are upstream of the proteasome including caspase and calpain. Emerging data suggest that targeted inhibition of these pathways may alter the evolution and progression of sepsis-induced myopathy and potentially reduce the occurrence of sepsis-mediated acquired weakness syndromes.

A framework for diagnosing and classifying intensive care unit-acquired weakness

Neuromuscular dysfunction is prevalent in critically ill patients, is associated with worse short-term outcomes, and is a determinant of long-term disability in intensive care unit survivors. Diagnosis is made with the help of clinical, electrophysiological, and morphological observations; however, the lack of a consistent nomenclature remains a barrier to research. We propose a simple framework for diagnosing and classifying neuromuscular disorders acquired in critical illness.

Bed rest in health and critical illness: a body systems approach

Bed rest is a common intervention for critically ill adults. Associated with both benefits and adverse effects, bed rest is undergoing increasing scrutiny as a therapeutic option in the intensive care unit. Bed rest has molecular and systemic effects, ultimately affecting functional outcomes in healthy individuals as well as in those with acute and critical illnesses. Using empirical sources, the purpose of this article was to describe the consequences of bed rest and immobility, especially consequences with implications for critically ill adults in the intensive care unit. This review uses body systems to cluster classic and current results of bed rest studies, beginning with cardiovascular and including pulmonary, renal, skin, nervous, immune, gastrointestinal/ metabolic, and skeletal systems. It concludes with effects on muscles, a system profoundly affected by immobility and bed rest.

An explorative study on quality of life and psychological and cognitive function in pediatric survivors of septic shock

OBJECTIVE

To evaluate self-reported health-related quality of life, anxiety, depression, and cognitive function in pediatric septic shock survivors.

DESIGN

A retrospective cohort study.

SETTING

A 14-bed tertiary pediatric intensive care unit.

PATIENTS

Children aged >or=8 yrs at the time of the follow-up who were admitted between 1995 and 2004 for septic shock. Inotropic and or vasoconstrictive agents were administered to these patients for >or=24 hrs.

INTERVENTION

Health-related quality of life was assessed with the KIDSCREEN-52, anxiety with the State Trait Anxiety Inventory for Children, depression with the Children's Depression Inventory, and cognitive function with the cognitive scale of the TNO-AZL Children's Quality of Life Questionnaire Child Form.

MEASUREMENTS AND MAIN RESULTS

Fifty of 82 eligible pediatric septic shock survivors were evaluated. The median age of the children at pediatric intensive care unit admission was 4.2 yrs (range, 0.0-17.0 yrs); the median age at follow-up was 10.7 yrs (range, 8.0-20.4 yrs). Health-related quality of life and anxiety scores were comparable to the age-related Dutch norm population. Depression scores were significantly better than the norm population, whereas cognitive function was significantly lower than the norm population. We found that 44% of the children had cognitive scores <25% of the norm population. Young age at the time of pediatric intensive care unit admission was predictive of cognitive problems, and cognitive problems were associated with lower emotional function.

CONCLUSIONS

In this group of septic shock survivors, health-related quality of life, anxiety, and depression are equal to or slightly better than the age-related Dutch norm population. Cognitive function is decreased, especially in children admitted at younger ages. Follow-up studies with adequate neuropsychological testing are warranted to evaluate the association between septic shock, cognitive function, and risk factors for cognitive problems.

Education and support needs during recovery in acute respiratory distress syndrome survivors

Introduction

There is a limited understanding of the long-term needs of survivors of the acute respiratory distress syndrome (ARDS) as they recover from their episode of critical illness. The Timing it Right (TIR) framework, which emphasizes ARDS survivors' journey from the ICU through to community re-integration, may provide a valuable construct to explore the support needs of ARDS survivors during their recovery.

Methods

Twenty-five ARDS survivors participated in qualitative interviews examining their needs for educational, emotional and tangible support for each phase of the TIR framework. Transcripts were analyzed using framework methodology.

Results

ARDS survivors' support needs varied across the illness trajectory. During the ICU stay, survivors were generally too ill to require information. The transfer to the general ward was characterized by anxiety surrounding decreased surveillance and concern for future health and treatment. Information needs focused on the events surrounding the acute illness, while physical and emotional needs revolved around physical therapy and psychological support for depression and anxiety. As patients were preparing for hospital discharge, they expressed a desire for specific information about the recovery and rehabilitation process following an episode of ARDS (e.g., outpatient physiotherapy, long-term sequela of the illness). Once in the community, survivors wanted guidance on home care, secondary prevention, and ARDS support groups.

Conclusions

Our findings support the need for future educational and support interventions to meet the changing needs of ARDS survivors during their recovery.

Glucose control in sepsis

Hyperglycemia is common during the course of critical illness and is associated with adverse clinical outcomes. Randomized controlled trials and large observational trials of insulin therapy titrated to achieve glucose values approximating the normal range (80 to 110 mg/dL) demonstrate improved morbidity and mortality in heterogeneous populations and have led to recommendations for improved glucose control. Patients who have septic shock, however, appear to be at higher risk for hypoglycemia, and a recent randomized trial focusing exclusively on patients who had severe sepsis did not show benefit. The recent Surviving Sepsis consensus statement recommends insulin therapy using validated protocols to lower glucose (less than 150 mg/dL) pending the results of adequately powered trials to determine if normalization (less than 110 mg/dL) of glucose is needed to optimize outcomes in patients who have severe sepsis.

Types of brain dysfunction in critical illness

Cerebral dysfunction and injury in the ICU presents as focal neurologic deficits, seizures, coma, and delirium. These syndromes may result from a primary brain insult, such as stroke or trauma, but commonly are a complication of a systemic insult, such as cardiac arrest, hypoxemia, sepsis, metabolic derangements, and pharmacologic exposures. Many survivors of critical illness have cognitive impairment, which is believed to underlie the poor long-term functional status and quality of life observed in many critical illness survivors. Although progress has been made in characterizing the epidemiology of cerebral dysfunction in the ICU, more research is needed to elucidate underlying mechanisms that might represent targets for therapeutic intervention.