Posttraumatic stress disorder in general intensive care unit survivors: a systematic review

The Sedative and Haemodynamic effects Of Continuous Ketamine infusions on Intensive Care Unit patients (SHOCK-ICU): Investigating key outcomes, resource utilisation and staff decision-making: Clinical feasibility study protocol

Background

Between April 2022 and March 2023, 43.8% (88,259) patients admitted to Intensive Care Units (ICU) in the United Kingdom (UK) required breathing support through a ventilator, the majority require sedation. Unfortunately, mechanical ventilation is associated with high mortality and morbidity, and sedative agents currently used have significant side effects including hypotension and delirium. They are also implicated in long-term psychological sequelae such as major depression and posttraumatic stress disorder. Ketamine has been utilised in anaesthesia for over 50 years and has an excellent safety profile. The diverse properties of ketamine are the focus of much research currently, including its properties as a potent antidepressant. Ketamine has not been fully investigated in the context of ICU, and there are gaps in the evidence that warrant further investigation through a large randomised controlled trial. Preparatory work for such a study includes refining study designs, identifying key clinical and patient centred outcomes and exploring barriers to implementation, which is the focus of this work.

Methods

SHOCK-ICU is a single centre, non-randomised, feasibility study assessing the feasibility of continuous ketamine infusions for the provision of sedation for 30 patients undergoing mechanical ventilation on the ICU.Data will be collected at baseline, daily until >48 h without mechanical ventilation, ICU discharge, and 90-days from enrolment. Data collection will include trial aspects such as expected recruitment, refusal, and follow-up rates, ability to collect data, and exploratory assessment of clinical efficacy markers.

Primary outcome

The primary outcome is study feasibility; this will be assessed using pre-defined progression criteria that will aid design of future ketamine sedation studies.

Quality of Life and Mental Health in COVID-ARDS Survivors After V-V ECMO Support: Results from the Freiburg ECMO Outcome Study (FEOS)

Introduction: Desirable outcome after venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome (ARDS) is frequently defined by survival. However, quality of life (QoL) and mental health status may take precedence over mere survival, from a patient-centered perspective. We aimed to evaluate QoL and mental health status in survivors after V-V ECMO for coronavirus disease 2019 (COVID-19)-related ARDS, hypothesizing a similar QoL comparable to the general population. Methods: All patients supported with venovenous ECMO for COVID-19-related ARDS between 01/2020 and 03/2022 in our center were included. Survivors were invited to participate in a follow-up interview assessing QoL, anxiety, and depression one year after hospital discharge. Primary endpoint was the quality of life, measured by the SF-36 questionnaire, with results compared to data from the DEGS1 study (German normative population). Results: During the study period, 97 patients received venovenous ECMO for COVID-19 ARDS at our ICU. Overall, 43/97 (44.3%) survived, and 21/97 (21.6%) completed the SF-36 questionnaire. The median follow-up duration was 1.7 years. Patients who completed the SF-36 were significantly younger than those who did not (48.7 vs. 55.6 years, p = 0.012); other patient characteristics and ECMO parameters were similar between those with and without questionnaire. Anxiety, depression, and post-traumatic stress disorder were detected in 33%, 14%, and 29% of patients, respectively. Compared to the German normative population, ECMO survivors had significantly lower QoL (mean 77.2 vs. 61.0, p < 0.001). Conclusions: QoL and mental health status after venovenous ECMO for ARDS was significantly lower compared to the normative population. These findings highlight the importance of further research and comprehensive follow-up care for ECMO survivors.

Optimizing Administration and Timing of Post Intubation Analgesia and Sedation in the Emergency Department

INTRODUCTION

Recent literature suggests pain management and sedation in ED patients after rapid sequence intubation are done inconsistently, which impacts patient outcomes negatively. The purpose of this study is to compare rates and timing of post-intubation analgesia and sedation before and after an ED pharmacy practice improvement intervention.

METHODS

We conducted a retrospective study of adult ED patients intubated over an 18-month period. The primary study endpoint was the frequency of post-intubation analgesia and sedation administration before and after implementation of the post-intubation guideline and education. Secondary endpoints included time to analgesia and sedation medication after paralytic administration, comparison between paralytic drugs utilized (succinylcholine and rocuronium), and ED length of stay.

RESULTS

Prior to intervention, the mean percentage of post-intubation analgesia and sedation administration was 58.6% and 94.3%, respectively. After paralytic administration, the time to dose of analgesia was 63 minutes (range 0-288) and 47 minutes for sedation medication (range 0-214). The mean length of stay in the emergency department was 298 minutes (range 12-3143). Following the intervention, 35 patients met inclusion criteria, and the mean percentage of analgesia and sedation administration was 77.1% and 91.4%, respectively. The mean time to analgesia administration improved to 22 minutes (range 0-123), and sedation improved to 20 minutes (range 0-284). The mean emergency department length of stay decreased to 204 minutes (range 46-469). When comparing paralytic used, mean time to analgesia and sedation was longer in those who received rocuronium compared to succinylcholine.

DISCUSSION

An educational lecture along with a novel ED post-intubation clinical guideline improved rates and timing to analgesia and sedation. This provides a unique opportunity for emergency nurses to advocate for early analgesia and sedation in mechanically ventilated patients.

Associations Between Elevated Rates of Depression, Anxiety, and PTSD Among ICU Survivors and Increased Mortality and Readmissions

PURPOSE

Intensive care unit (ICU) mortality has decreased, highlighting improved patient outcomes. However, other critical factors affect post-ICU survival, including lasting physical, cognitive, and psychological challenges termed postintensive care syndrome (PICS), encompassing depression, anxiety, and posttraumatic stress disorder (PTSD). The prevalence of these conditions among ICU survivors is high and potentially linked to ICU treatment. This study aims to understand these factors using Taiwan's National Health Insurance Research Database (NHIRD), exploring their impact on mortality and readmission rates post-ICU discharge.

METHODS

The National Health Insurance (NHI) program in Taiwan, implemented in 1995, provides healthcare for nearly all residents. Its research arm, NHIRD, contains comprehensive medical data for nationwide studies. This research focuses on ICU patients with specific conditions from 2010 to 2018, using ICD codes for diagnosis. Statistical analyses include Cox proportional hazard models and logistic regression, aiming to assess the incidence and risks of anxiety/depression/PTSD.

RESULTS

ICU patients showed a higher risk of anxiety/depression/PTSD compared to non-ICU patients (adjusted HR = 1.17), with similar trends for anxiety and depression. Females, younger patients, those with higher CCI scores, on mechanical ventilators, and more extended hospital stays had increased odds of anxiety/depression/PTSD. ICU patients with anxiety/depression/PTSD faced increased risks of death and re-admission, especially among older males with comorbidities.

CONCLUSION

This study discovered higher anxiety and depression rates post-ICU compared to general ward patients, particularly among younger individuals, females, and those with longer hospital stays. Factors such as higher comorbidity scores and mechanical ventilation use were linked to lower odds. Addressing mental health postdischarge is crucial, especially for at-risk groups.

Posttraumatic stress and growth in pulmonary patients recovered from COVID-19

The COVID-19 pandemic has profoundly affected mental health, with many survivors experiencing psychological challenges, including Post-Traumatic Stress Disorder (PTSD). This study assessed PTSD symptoms and Post-Traumatic Growth (PTG) among 62 individuals recovering from COVID-19 infection, all of whom were under the care of the Department of Pneumonology, Oncology, and Allergology at the Medical University of Lublin. Results revealed that 40.32% of participants exhibited PTSD symptoms. Key predictors of PTSD severity included cognitive symptoms and post-COVID self-rated health, with cognitive symptoms positively associated and self-rated health negatively associated with PTSD severity. A positive correlation was also found between PTSD severity and PTG, suggesting that while individuals endure significant psychological distress, they may also experience personal growth, such as enhanced resilience and a redefined life perspective. These findings highlight the dual psychological impact of COVID-19 infection, particularly for individuals with preexisting pulmonary conditions. They underscore the importance of holistic, integrated care that addresses both the reduction of PTSD symptoms and the promotion of meaningful psychological growth in COVID-19 survivors.

Trauma-related psychopathologies after extracorporeal membrane oxygenation support: A systematic review and meta-analysis

Extracorporeal Membrane Oxygenation (ECMO) use is associated with substantial psychiatric morbidity in patients and their families. This systematic review and meta-analysis quantifies the prevalence of post-traumatic stress disorder (PTSD), anxiety, and depression among ECMO survivors and their families. Included studies enrolled patients on ECMO or their families and reported at least one trauma-related psychopathology. Of 1767 screened studies, 55 were included (5146 participants): 50 in adult ECMO survivors, one in pediatric ECMO survivors, and four in families of ECMO patients (two adult, two pediatric.). The pooled prevalence of PTSD was 19% in adult ECMO survivors, 20% in pediatric ECMO survivors, 25% in families of adult ECMO patients, and 21% in families of pediatric ECMO patients. The pooled prevalence of anxiety was 30% in adult ECMO survivors, 8% in pediatric ECMO survivors, 67% in families of adult ECMO patients, and 46% in families of pediatric ECMO patients. The pooled prevalence of depression was 24% in adult ECMO survivors, 8% in pediatric ECMO survivors, 50% in families of adult ECMO patients, and 32% in families of pediatric ECMO patients. This meta-analysis demonstrates a high prevalence of trauma-related psychopathologies surrounding ECMO use, highlighting the need for interventions to improve post-ECMO outcomes.

Post-Intensive Care Syndrome-Mental Health

Intensive care unit (ICU) survivors experience longstanding psychological impairments that persist in the months to years following ICU discharge, regardless of severity of illness or extent of physical recovery. Risk factors for psychological problems following critical illness have been identified including early symptoms of acute stress. Assessment of psychological symptoms in ICU patients and survivors remains inconsistent and many do not receive appropriate psychological evaluation, diagnosis, or treatment. Screening patients for psychological impairments early and serially following hospitalization is crucial to addressing patients' needs and mitigating long-term distress, as is connecting patients to outpatient mental health follow-up for treatment.

Risk factors for PTSD symptoms following PICU admission for childhood septic shock

ObjectivePaediatric intensive care unit (PICU) admission represents a traumatic event for many children. Follow-up studies have found post-traumatic stress disorder (PTSD) rates of 10-30%, with a particular prevalence following admission for sepsis. Dysregulated inflammatory responses are associated with PTSD. Sepsis involves a marked inflammatory response but the relationship between this and PTSD have not been clearly established. In this study we investigate associations between the inflammatory response, psychosocial risk factors, and PTS symptoms following PICU admission for septic shock.We investigate the outcomes for children aged > 3 years, discharged from one PICU following admission for septic shock between 2010 and 2017. The study was a retrospective analysis of PICU-specific PTS symptoms reported by parents at any time since discharge via the Trauma and Behavior Health screen. Demographics, pre-morbid health characteristics, and exposure to other traumatic events were assessed. Clinical characteristics and blood test results at admission and at 48 h were recorded from clinical records. Multiple linear regression was used to investigate relationships between PTS symptom scores and predictor variables.Data for 65 participants (48% male, median assessment age 8.0 years) was available. Median time since admission was 5.1 years. 30.8% children scored at risk of PTSD at any time since discharge Symptoms were significantly associated with acute CRP rise (p 0.03), other trauma exposures (p = 0.01), and female gender (p =0.04).PTS symptoms in children who have survived septic shock are prevalent. These findings support a possible contribution of acute inflammatory changes, cumulative traumatic exposure, and female gender in post-PICU PTSD development.

Patient Characteristics and Practice Variation Associated With New Community Prescription of Benzodiazepine and z-Drug Hypnotics After Critical Illness: A Retrospective Cohort Study Using the UK Clinical Practice Research Datalink

PURPOSE

Survivors of critical illness are often affected by new or worsened mental health conditions and sleep disorders. We examined the incidence, practice variation and factors associated with new benzodiazepine and z-drug community prescriptions among critical illness survivors.

METHODS

A retrospective cohort study using the UK Clinical Practice Research Datalink data included 52 846 adult critical care survivors hospitalised in 2010 and 2018 who were not prescribed benzodiazepines or z-drugs before hospitalisation. We performed multilevel multivariable logistic regression to assess patient factors associated with new (any prescription within 90 days) and with new-and-persistent (2+ prescriptions within 180 days) benzodiazepine or z-drug prescribing, and to evaluate variation by primary care practice.

RESULTS

5.2% (2769/52846) of treatment-naïve survivors (95% CI 5.1-5.4) were prescribed a benzodiazepine or z-drug, and 2.5% (1311/52846) had new-and-persistent prescribing. A history of insomnia (adjusted OR 1.96; 95% CI 1.74-2.21), anxiety or depression (adjusted OR 1.40; 95% CI 1.28-1.53) and recent prescription opioid use (adjusted OR 1.47; 95% CI 1.34-1.61) were associated with new community prescription. Sex was not associated with new prescriptions and older patients were less likely to receive a prescription. 2.6% of the variation in new prescribing and 4.1% of the variation in new-and-persistent prescribing were attributable to the prescribing practice.

CONCLUSIONS

One in twenty critical illness survivors receive a new community benzodiazepine or z-drug prescription. Further research is needed to understand where in the patient care pathway initiation occurs and the risk of adverse events in survivors of recent critical illness.

Evaluation of the mental health of COVID-19 patients discharged from the intensive care unit

In this editorial, I address the mental health status of patients who have been discharged from intensive care units (ICUs) after battling coronavirus disease 2019 (COVID-19). An ICU admission is generally a stressful experience, and for severe COVID-19 survivors prolonged treatment in the ICU can lead to significant psychological consequences. These individuals may experience psychiatric distress, including symptoms such as insomnia, anxiety, depression, and even post-traumatic psychological issues. Research indicates that during the first 6 months to 1 year following an ICU stay, nearly one-third of survivors exhibit symptoms similar to those of depression and post-traumatic stress disorder. Several factors may have contributed to the development of depressive and anxious symptoms during the COVID-19 pandemic, particularly for those who underwent an ICU stay. The ICU environment itself is inherently stressful, filled with the constant noise of various medical devices. Studies have provided strong evidence that the prolonged need for ventilation support and the loss of freedom of movement are key factors in the development of psychological problems among COVID-19 patients who had been treated in the ICU.

Factors Influencing Stress Disorders in Intensive Care Unit (ICU) Patients After Liver Transplantation: A Cross-Sectional Study

BACKGROUND Evidence on psychological factors associated with post-transplant post-traumatic stress disorder (PTSD) in liver transplantation (LT) patients is limited. Identifying the psychological factors associated with post-transplant PTSD would help to understand the symptoms of PTSD and take preventive measures. The aim of this study was to investigate factors influencing stress disorders in Intensive Care Unit (ICU) patients 1 year after LT. MATERIAL AND METHODS We assessed data from 184 LT patients at our hospital between January 2020 and December 2022. According to the PCL-C score, the patients were divided into the PTSD group (score ≤37) and the non-PTSD group (score >37). The demographic data, clinical data, the pain visual analogue scale (VAS), the anxiety and depression scale (HADS), and the psychological resilience scale (CD-RISC score) were compared between the 2 groups. Pearson correlation analysis was used to analyze the correlation between PCL-C and VAS, HADS, and CD-RISC, and logistic regression was used to analyze the factors influencing PTSD. SPSS 23.0 software was used for statistical analysis. RESULTS The average age of the 184 participants was 53.17 years (±3.47) and 66.85% of the subjects were male. The prevalence rate of post-transplant PTSD was 22.83% and the total score on the PCL-C scale was 32.47±7.81. Pearson correlation analysis showed that PCL-C score was positively correlated with VAS (r=0.312, P=0.012) and HADS (r=0.412, P<0.001), and negatively correlated with CD-RISC (r=-0.468, P<0.001). Logistic regression analysis showed that the symptom of post-transplant PTSD was significantly associated with higher VAS (OR=1.058, P=0.007) and HADS (OR=1.885, P<0.001) scores and lower CD-RISC (OR=2.213, P<0.001) score, which indicated that higher VAS and HAD scores were risk factors that contributed to PTSD and lower CD-RISC was a protective factor against PTSD. CONCLUSIONS We found that pain, anxiety, depression, and resilience were associated with symptoms of PTSD in LT patients in the ICU. Nursing staff should seek to relieve their patients' pain and assure provision of targeted health education and personalized psychological counseling to reduce the risk of PTSD after LT.

Incidence and risk factors of Post-intensive care syndrome (PICS) in surgical ICU survivors: a prospective Chinese cohort study

BACKGROUND

Post-intensive care syndrome (PICS) is a term coined by the Society of Critical Care Medicine to describe the psychological, cognitive, and physical dysfunction that ICU survivors may experience. Although surgical patients represent a substantial proportion of ICU survivors, studies describing PICS in this specific population remain limited. This study aims to determine the incidence and independent risk factors associated with PICS among surgical ICU survivors in a Chinese cohort.

METHODS

The study was a prospective cohort study of critically ill surgical patients who were discharged from the ICU at the First Affiliated Hospital of Sun Yat-sen University between August 2021 and June 2022. Demographic characteristics, disease-related information, and ICU treatment were collected, and enrolled participants were followed up within six months after ICU discharge. The Chinese version of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) and the Short Memory Questionnaire (SMQ) were used to assess PICS. The physical component summary (PCS) and the mental component summary (MCS) were averaged from the corresponding four-dimension scores in the SF-36. PICS diagnosis was determined based on the presence of at least one of the following: physiological dysfunction (defined as PCS reductions greater than 10), psychological dysfunction (defined as MCS reductions greater than 10), or cognitive dysfunction (defined as SMQ reductions and scores less than 40 at six months). PICS diagnosis was based on the presence of at least one of the following: physiological, psychological, or cognitive dysfunction.

RESULTS

A total of 565 patients were screened in this study, and 83 were enrolled after applying the inclusion and exclusion criteria. Overall, 65 surgical ICU survivors developed PICS within six months, with an incidence rate of 78.3%. The prevalences were 55.4% and 27.7% at the end of 3 and 6 months after ICU discharge, respectively. Univariate analysis showed that there was a correlation between the occurrence of PICS and the total bilirubin and creatinine levels at ICU admission, APACHE II score, ICU length of stay, and the presence of dialysis (P < 0.05). ICU length of stay was identified as an independent risk factor for the occurrence of PICS in surgical ICU survivors after adjusting for confounders.

CONCLUSION

The overall PICS incidence in surgical ICU survivors was 78.3%, with prevalence gradually decreasing over time to 27.7% within 6 months. For surgical survivors requiring ICU care, the longer the ICU stay, the more likely to develop PICS.

IMPLICATIONS FOR CLINICAL PRACTICE

The findings offer valuable insights into the incidence and risk factors of PICS in surgical ICU survivors, which can help healthcare professionals identify surgical cases at high risk of developing PICS and tailor the treatment effectively.

Relationship between critical illness recovery and social determinants of health: a multiperspective qualitative study in British Columbia, Canada

OBJECTIVES

There are health disparities and inequities in the outcomes of critical illness survivors related to the influence of social determinants of health on recovery. The purpose of this study was to describe the relationship between critical illness recovery and the intermediary social determinants of health in the Canadian context. Because Canadian healthcare is provided within a universal publicly funded system, this analysis sheds light on the role of social determinants of health in the context of universal health services and a relatively robust social safety net.

DESIGN

In this qualitative interpretive description study, data from semi-structured interviews with intensive care unit survivors, family caregivers and healthcare providers were analysed using thematic and constant comparative methods.

SETTING

Western Canadian Hospital serving a population of 900 000 people.

PARTICIPANTS

The 74 study participants included 30 patients (mean age 58 years, 18 men and 12 women) and 25 family caregivers (mean age 55 years, 8 men and 17 women), representing 37 cases, as well as 19 healthcare providers.

RESULTS

Challenges with employment and finances, home set-up, transportation, food and nutrition, medications and social support complicated and hindered critical illness recovery. Critical illness sequelae also altered these social determinants of health, suggesting a reciprocal relationship. Furthermore, individuals experiencing socioeconomic disadvantage before critical illness described being at a greater disadvantage following their critical illness, which interfered with their recovery and suggests an accumulation of risk for some.

CONCLUSIONS

Our findings underscore the significant influence of social determinants of health on critical illness recovery, highlighting the importance of creating and evaluating comprehensive approaches to health and well-being that address health inequities.

Long-term sequelae and management following obstetric sepsis

The long-term consequences of obstetric sepsis have been a growing area of concern requiring attention. This narrative review summarizes the existing literature on the long-term sequelae of sepsis, with a focus on the antepartum and postpartum periods. In this article, we discuss risk factors for and epidemiology of post-sepsis syndrome (PSS) and related long-term medical conditions. We include recommendations for screening for PSS and management strategies involving multidisciplinary teams. PSS and other long-term medical and psychological sequelae of sepsis impact individuals and their communities greatly, including the obstetric population. There is a need for improved identification, management, and coordination of care for long-term complications of sepsis. Gaps in the literature for future study include identifying specific needs of the obstetric population in the weeks, months, and years following a sepsis event.

Post-Intensive Care Syndrome as a Burden for Patients and Their Caregivers: A Narrative Review

Millions of critically ill patients are discharged from intensive care units (ICUs) every year. These ICU survivors may suffer from a condition known as post-intensive care syndrome (PICS) which includes a wide range of cognitive, psychological, and physical impairments. This article will provide an extensive review of PICS. ICU survivors may experience cognitive deficits in memory and attention, with a slow-down of mental processing and problem-solving. From psychological perspectives, depression, anxiety, and post-traumatic stress disorder are the most common issues suffered after ICU discharge. These psycho-cognitive impairments might be coupled with ICU-acquired weakness (polyneuropathy and/or myopathy), further reducing the quality of life, the ability to return to work, and other daily activities. The burden of ICU survivors extends to families too, leading to the so-called PICS-family (or PICS-F), which entails the psychological impairments suffered by the family and, in particular, by the caregiver of the ICU survivor. The development of PICS (and PICS-F) is likely multifactorial, and both patient- and ICU-related factors may influence it. Whilst the prevention of PICS is complex, it is important to identify the patients at higher risk of PICS, and clinicians should be aware of the tools available for diagnosis. Stakeholders should implement strategies to achieve PICS prevention and to support its effective treatment during the recovery phase with dedicated pathways and supporting care.

Survivorship After Neurocritical Care: A Scoping Review of Outcomes Beyond Physical Status

Following intensive care unit hospitalization, survivors of acute neurological injury often experience debilitating short-term and long-term impairments. Although the physical/motor impairments experienced by survivors of acute neurological injury have been described extensively, fewer studies have examined cognitive, mental health, health-related quality of life (HRQoL), and employment outcomes. This scoping review describes the publication landscape beyond physical and/or motor sequelae in neurocritical care survivors. Databases were searched for terms related to critical illness, intensive care, and outcomes from January 1970 to March 2022. English-language studies of critically ill adults with a primary neurological diagnosis were included if they reported on at least one outcome of interest: cognition, mental health, HRQoL or employment. Data extraction was performed in duplicate for prespecified variables related to study outcomes. Of 16,036 abstracts screened, 74 citations were identified for inclusion. The studies encompassed seven worldwide regions and eight neurocritical diagnosis categories. Publications reporting outcomes of interest increased from 3 before the year 2000 to 71 after. Follow-up time points included ≤ 1 (n = 15 [20%] citations), 3 (n = 28 [38%]), 6 (n = 28 [38%]), and 12 (n = 21 [28%]) months and 1 to 5 (n = 19 [26%]) and > 5 years (n = 8 [11%]), with 28 (38%) citations evaluating outcomes at multiple time points. Sixty-six assessment tools were used to evaluate the four outcomes of interest: 22 evaluating HRQoL (56 [76%] citations), 21 evaluating cognition (20 [27%] citations), 21 evaluating mental health (18 [24%] citations), and 2 evaluating employment (9 [12%] citations). This scoping review aimed to better understand the literature landscape regarding nonphysical outcomes in survivors of neurocritical care. Although a rising number of publications highlight growing awareness, future efforts are needed to improve study consistency and comparability and characterize outcomes in a disease-specific manner, including outlining of a minimum core outcomes set and associated assessment tools.

Risk factors of post-traumatic stress disorder after hospitalization in a pediatric intensive care unit: a systematic literature review

The number of studies on post-traumatic stress disorder after hospitalization in a pediatric intensive care unit raised since 2004. The objective of this systematic review was to summarize and critically examine the literature about risk factors for these children to develop post-traumatic stress disorder following admission to an intensive care unit. The data sources were PubMed, Cochrane, Web of Science, PsycInfo, SUDOC, Scopus, and ScienceDirect. Studies were selected if they were in English or French and published between 01/01/2004 and 31/01/2022. Studies were excluded if patients were less than 1 month old and if no post-traumatic stress disorder was found. The internal validity and risk of bias were assessed using the National Institutes of Health Study Quality Assessment Tools for observational studies and the Ottawa Scale was used for the interventional study. The search yielded 523 results and 22 articles met inclusion criteria. Three common risk factors were identified from the data: parental post-traumatic stress disorder (especially in mothers), severity of illness and delusional memories. Internalizing behavior in children, acute parent and child stress, emergency admission and sepsis are also potential risk factors that require further investigation. The prevalence of this pathology is substantial (between 14 and 36%) and increasing awareness among pediatricians and psychologists seems necessary. Prevention programs are being studied to reduce the incidence of post-traumatic stress disorder in this population. Child and adolescent psychiatry liaison should collaborate with pediatric teams to support this objective.

"The Psychiatric Domain of Post-Intensive Care Syndrome: A Review for the Intensivist"

Post-intensive care syndrome (PICS) is a clinical syndrome characterized by new or worsening changes in mental health, cognition, or physical function that persist following critical illness. The psychiatric domain of PICS encompasses new or worsened psychiatric burdens following critical illness, including post-traumatic stress disorder (PTSD), depression, and anxiety. Many of the established predisposing and precipitating factors for the psychiatric domain of PICS are commonly found in the setting of critical illness, including mechanical ventilation (MV), exposure to sedating medications, and physical restraint. Importantly, previous psychiatric history is a strong risk factor for the development of the psychiatric domain of PICS and should be considered when screening patients to diagnose psychiatric impairment and interventions. Delirium has been associated with psychiatric symptoms following ICU admission, therefore prevention warrants careful consideration. Dexmedetomidine has been shown to have the lowest risk for development of delirium when compared to other sedatives and has been the only sedative studied in relation to the psychiatric domain of PICS. Nocturnal dexmedetomidine and intensive care unit (ICU) diaries have been associated with decreased psychiatric burden after ICU discharge. Studies evaluating the impact of other intra-ICU practices on the development of the psychiatric domain of PICS, including the ABCDEF bundle, depth of sedation, and daily spontaneous awakening trials, have been limited and inconclusive. The psychiatric domain of PICS is difficult to treat and may be less responsive to multidisciplinary post-discharge programs and targeted interventions than the cognitive and physical domains of PICS. Given the high morbidity associated with the psychiatric domain of PICS, intensivists should familiarize themselves with the risk factors and intra-ICU interventions that can mitigate this important and under-recognized condition.

Physical function measures in ICU survivors, where to now? A scoping review

Background

Growing evidence is describing the long-term morbidity experienced by critical illness survivors, a major contributing factor being impaired physical function. Consensus is yet to be reached on which physical function measures should be included in this population. This review aimed to describe physical functioning measurement instruments used in longitudinal studies of critical illness survivors, based on the International Classification of Function (ICF).

Methods

An electronic database search of EbscoHost, Web of Science and Scopus was conducted from inception to November 2023. Two reviewers independently applied the inclusion and exclusion criteria to titles, abstracts and full text-studies. Extracted data included year of publication; country; participant age; follow-up timeframes and physical measurement instruments used. Instruments were classified according to ICF domains.

Results

Eighty studies published between 1995 and November 2023 were included. Forty-four different outcome measures were identified. Most studies (68) included multiple followed-up points and were completed within a year, and few studies (12) follow-up beyond a year. Based on the ICF, 11 (25%) instruments measured impairments and 33 (75%) activity limitations. Muscle power functions were the most frequently measured impairment (65%), utilising manual muscle testing (37.3%). The six-minute walk test (6MWT) was the most frequently used instrument in the activity/participation domain (31.6%). Only one instrument addressed all five the physical activity/participation domains, while the majority focused on mobility domain.

Conclusion

Multiple tools are used to report on physical deficits experienced by ICU survivors, either measuring impairments or activity/ participation limitations. Most studies report on physical function within the first year of survival. The heterogeneity and inconsistency over time of instruments used prevents synthesis of data to determine intervention efficacy. The validity, predictive value and sensitivity of the reported measures within ICU survivors needs to be established, only then can intervention studies be designed to measure effectiveness.

Contribution of the study

This scoping review contributes to the existing literature and development of standardised core outcome measure sets (COMS) for critical illness research by providing a comprehensive and systematic mapping of physical function measurement instruments utilised in longitudinal studies of critical illness survivors. By categorising these instruments according to the International Classification of Functioning, Disability and Health (ICF) framework, the review offers a novel perspective on the current state of outcome measurement in this field.

Antidepressant drug use after intensive care: a nationwide cohort study

Modern intensive care has improved survival rates, but emerging evidence suggests a high prevalence of post-intensive care unit (ICU) health problems, including post-traumatic stress disorder, depression and anxiety. These symptoms may have a detrimental effect on quality of life and increase mortality. The primary objective of this study is to examine the extent of initiation of antidepressant medication among ICU survivors and identify the factors associated with its usage. The secondary objective is to investigate whether the use of these medications is linked to an increased mortality. The nationwide study cohort included 125,130 ICU survivors admitted between 2010 and 2017. Within the first 3 months after ICU discharge, 7% of patients initiated antidepressant medication, by 1 year 15.5% had started medication. We found no tendency to a decrease during the 2-year follow-up period. Factors associated with antidepressant use included middle age, female sex, psychiatric and somatic comorbid conditions, substance dependence, higher illness severity, and longer ICU stay. Antidepressant users had a higher mortality rate, and deaths due to external causes and suicide were more frequent in this group. This study emphasizes the importance of detecting and addressing depression in ICU survivors to improve their quality of life and reduce mortality rates.

Touching the unconscious in the unconscious - hypnotic communication with unconscious patients

If hypnosis means contact to the unconscious to modulate psychological and physiological functions by means of suggestions, and if this is facilitated by attenuation of the critical mind, then the question arises as to whether suggestions also have an effect when waking consciousness is otherwise eliminated, namely by coma or anesthesia. A prerequisite would be perception, which actually is evidenced by reports of patients after traumatic brain injury, artificial coma, resuscitation or general anesthesia. Moreover, posttraumatic stress disorder (PTSD) frequently observed after these medical situations is hardly explainable without some sort of awareness under such conditions. Even advanced neurophysiological diagnostic cannot yet rule out consciousness or sensory processing. Especially reference to perception during unconsciousness is given by the results of a recent multicenter study on the effects of hypnotic communication with patients under controlled adequate deep general anesthesia. The observed reductions in incidence and severity of postoperative pain, opioid use, nausea and vomiting cannot be explained by the reaction of a few but only by a considerable proportion of patients. This leads to a strong plea for a more careful treatment of unconscious patients in the emergency room, operating theater or intensive care unit, for the abandonment of the restriction of therapeutic communication to awake patients, and for new aspects of communication and hypnosis research. Obviously, loss of consciousness does not protect against psychological injury, and continuation of communication is needed. But how and what to talk to unconscious patients? Generally addressing the unconscious mind with suggestions that generally exert their effects unconsciously, hypnotic communication appears to be the adequate language. Especially addressing meaningful topics, as derived from the basic psychological needs and known stressors, appears essential. With respect to negative effects by negative or missing communication or to the proposed protective and supporting effects of therapeutic communication with patients clinically rated as unconscious, the role of consciousness is secondary. For the effects of perceived signals and suggestions it does not matter whether consciousness is absent, or partial, or unrecognized present.

Unmasking the hidden aftermath: postintensive care unit sequelae, discharge preparedness, and long-term follow-up

A significant portion of individuals who have experienced critical illness encounter new or exacerbated impairments in their physical, cognitive, or mental health, commonly referred to as postintensive care syndrome. Moreover, those who survive critical illness often face an increased risk of adverse consequences, including infections, major cardiovascular events, readmissions, and elevated mortality rates, during the months following hospitalization. These findings emphasize the critical necessity for effective prevention and management of long-term health deterioration in the critical care environment. Although conclusive evidence from well-designed randomized clinical trials is somewhat limited, potential interventions include strategies such as limiting sedation, early mobilization, maintaining family presence during the intensive care unit stay, implementing multicomponent transition programs (from intensive care unit to ward and from hospital to home), and offering specialized posthospital discharge follow-up. This review seeks to provide a concise summary of recent medical literature concerning long-term outcomes following critical illness and highlight potential approaches for preventing and addressing health decline in critical care survivors.

Post-Intensive Care Syndrome in Neurocritical Care Patients

Post-intensive care syndrome (PICS) refers to unintended consequences of critical care that manifest as new or worsening impairments in physical functioning, cognitive ability, or mental health. As intensive care unit (ICU) survival continues to improve, PICS is becoming increasingly recognized as a public health problem. Studies that focus on PICS have typically excluded patients with acute brain injuries and chronic neurodegenerative problems. However, patients who require neurocritical care undoubtedly suffer from impairments that overlap substantially with those encompassed by PICS. A major challenge is to distinguish between impairments related to brain injury and those that occur as a consequence of critical care. The general principles for the prevention and management of PICS and multidomain impairments in patients with moderate and severe neurological injuries are similar including the ICU liberation bundle, multidisciplinary team-based care throughout the continuum of care, and increasing awareness regarding the challenges of critical care survivorship among patients, families, and multidisciplinary team members. An extension of this concept, PICS-Family (PICS-F) refers to the mental health consequences of the intensive care experience for families and loved ones of ICU survivors. A dyadic approach to ICU survivorship with an emphasis on recognizing families and caregivers that may be at risk of developing PICS-F after neurocritical care illness can help improve outcomes for ICU survivors. In this review, we will summarize our current understanding of PICS and PICS-F, emerging literature on PICS in severe acute brain injury, strategies for preventing and treating PICS, and share our recommendations for future directions.

Patients' reports on their delusional memories from the intensive care unit: A systematic review of qualitative studies

OBJECTIVE

To critically summarise the qualitative literature to understand patients' experiences of delusional memories during their Intensive Care Unit stay.

RESEARCH METHODOLOGY

A systematic review of qualitative studies with meta-synthesis and meta-summary. We searched MEDLINE (via PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and Web of Science to July 2022. All studies that provided qualitative insights into the subjective experience of adult patients with delusional memories in the Intensive Care Unit were selected. The Critical Assessment Skills Programme checklist was used for the quality assessment.

RESULTS

Fourteen studies were included. The 33 codes that emerged from the inductive thematic analysis were grouped into three themes: 'The sense of danger and the terrifying aspect of death' (feeling in danger, surrounded by death, persecuted by people around, and feeling unsafe), 'The presence of someone or something nearby' (perceiving the loved ones, feeling overwhelmed by scary creatures, and being neglected by those around me), and 'The reality behind the world perceived by the senses' (travelling the world, stimulating the senses, feeling peaceful, and living in a fantasy world). The most frequent code in the studies was 'Be with a family member', with an intensity of 35.7%.

CONCLUSION

The patient's experience described as delusional is considered a real event by the person experiencing it. Further research is needed to investigate the extent to which these experiences lead to poorer early and late outcomes for patients, and to test strategies to prevent this.

IMPLICATIONS FOR CLINICAL PRACTICE

A deeper understanding of the phenomenon may help healthcare professionals to recognise precursors, symptoms and consequences of delusional memories and intervene with appropriate help. One strategy would be to further humanise care and focus on family involvement and communication with patients to overcome the factual events that can potentially alter patients' quality of life.

New-onset mental illness and long-term survival in survivors of critical illness: population-based cohort study in South Korea

BACKGROUND

Critical care unit (CCU) survivors have a high risk of developing mental illness.

AIMS

We aimed to examine the incidence and associated factors of newly developed mental illness among CCU survivors of critical illness. Moreover, we examined the association between newly developed mental illness and 2-year all-cause mortality.

METHOD

All adult patients (≥20 years) who were admitted to the CCU during hospitalisation between 2010 and 2018 and survived for 1 year were defined as CCU survivors and were included in this nationwide population-based cohort study. CCU survivors with a history of mental illness before CCU admission were excluded from the study.

RESULTS

A total of 1 353 722 CCU survivors were included in the analysis; of these, 33 743 survivors (2.5%) had newly developed mental illness within 1 year of CCU admission. Old age, longer CCU stay, hospital admission through the emergency room, increased total cost of hospitalisation, mechanical ventilatory support, extracorporeal membrane oxygenation support and continuous renal replacement therapy were associated with an increased incidence of newly developed mental illness. Moreover, the newly developed mental illness group showed a 2.36-fold higher 2-year all-cause mortality rate than the no mental illness group (hazard ratio: 2.36; 95% CI: 2.30-2.42; P < 0.001).

CONCLUSIONS

In South Korea, 2.5% of CCU survivors had newly developed mental illness within 1 year of CCU admission. Moreover, newly developed mental illness was associated with an increased 2-year all-cause mortality.

Impact of COVID-19 on posttraumatic stress disorder in ICU survivors: a prospective observational comparative cohort study

BACKGROUND

Posttraumatic stress disorder (PTSD) after a stay in the intensive care unit (ICU) can affect one in five ICU survivors. At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, admission to the ICU for COVID-19 was stressful due to the severity of this disease. This study assessed whether admission to the ICU for COVID-19 was associated with a higher prevalence of PTSD compared with other causes of ICU admission after adjustment for pre-ICU psychological factors.

METHODS

This prospective observational comparative cohort study included 31 ICUs. Eligible patients were adult ICU survivors hospitalized during the first wave of COVID-19 pandemic in France, regardless of the reason for admission. The prevalence of presumptive diagnosis of PTSD at 6 months was assessed using the PTSD Checklist for DSM-5 (PCL-5). Sociodemographics, clinical data, history of childhood trauma (Childhood Trauma Questionnaire [CTQ]), and exposure to potentially traumatic events (Life Events Checklist for DSM-5 [LEC-5]) were assessed.

RESULTS

Of the 778 ICU survivors included during the first wave of COVID-19 pandemic in France, 417 and 361 were assigned to the COVID-19 and non-COVID-19 cohorts, respectively. Fourteen (4.9%) and 11 (4.9%), respectively, presented with presumptive diagnosis of PTSD at 6 months (p = 0.976). After adjusting for age, sex, severity score at admission, use of invasive mechanical ventilation, ICU duration, CTQ and LEC-5, COVID-19 status was not associated with presumptive diagnosis of PTSD using the PCL-5. Only female sex was associated with presumptive diagnosis of PTSD. However, COVID-19 patients reported significantly more intrusion and avoidance symptoms than non-COVID patients (39% vs. 29%, p = 0.015 and 27% vs. 19%, p = 0.030), respectively. The median PCL-5 score was higher in the COVID-19 than non-COVID-19 cohort (9 [3, 20] vs. 4 [2, 16], p = 0.034).

CONCLUSION

Admission to the ICU for COVID-19 was not associated with a higher prevalence of PTSD compared with admission for another cause during the first wave of the COVID-19 pandemic in France. However, intrusion and avoidance symptoms were more frequent in COVID-19 patients than in non-COVID-19 patients.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier NCT03991611, registered on June 19, 2019.

Psychological symptoms and health-related quality of life in intubated and non-intubated intensive care survivors: A multicentre, prospective observational cohort study

Objective

To compare long-term psychological symptoms and health-related quality of life (HRQOL) in intubated versus non-intubated ICU survivors.

Design

Prospective, multicentre observational cohort study.

Setting

Four tertiary medical-surgical ICUs in Australia.

Participants

Intubated and non-intubated adult ICU survivors.

Main outcome measures

Primary outcomes: clinically significant psychological symptoms at 3- and 12-month follow-up using Post-Traumatic Stress Syndrome-14 for post-traumatic stress disorder; Depression, Anxiety Stress Scales-21 for depression, anxiety, and stress. Secondary outcomes: HRQOL, using EuroQol-5D-5L questionnaire.

Results

Of the 133 ICU survivors, 54/116 (47 %) had at least one clinically significant psychological symptom (i.e., post-traumatic stress disorder, anxiety, depression, stress) at follow-up. Clinically significant scores for psychological symptoms were observed in 26 (39 %) versus 16 (32 %) at 3-months [odds ratio 1.4, 95 % confidence interval (0.66-3.13), p = 0.38]; 23 (37 %) versus 10 (31 %) at 12-months [odds ratio 1.3, 95 % confidence interval (0.53-3.31), p = 0.57] of intubated versus non-intubated survivors, respectively. Usual activities and mobility were the most commonly affected HRQOL dimension, with >30 % at 3 versus months and >20 % at 12-months of overall survivors reporting ≥ moderate problems. There was no difference between the groups in any of the EQ5D dimensions.

Conclusions

Nearly one-in-two (47 %) of the intubated and non-intubated ICU survivors reported clinically significant psychological symptoms at 3 and 12-month follow-ups. Overall, more than 30 % at 3-months and over 20 % at 12-months of the survivors in both groups had moderate or worse problems with their usual activities and mobility. The presence of psychological symptoms and HRQOL impairments was similar between the groups.

Intensive Care Unit (ICU)-Related Post-traumatic Stress Disorder: A Literature Review

An intensive care unit (ICU) is a challenging environment characterized by frequent incidences of stressors and traumatic situations. Therefore, both patients and caregivers are at high risk of developing psychological disorders such as post-traumatic stress disorder (PTSD), anxiety, and depression. ICU-related PTSD is a significant concern that remains under-recognized. This literature review examines the current state of knowledge regarding ICU-related PTSD, including its prevalence, risk factors, clinical manifestations, and potential interventions. Key findings suggest that a considerable proportion of ICU survivors develop PTSD symptoms, which can significantly impact their quality of life and recovery. The most common predictors investigated for PTSD in ICU survivors are age, gender, pre-illness psychopathy, length of stay in the ICU, delirium, and sedative agents. The treatment and prevention strategies of ICU-related PTSD include psychological therapies and pharmacological and non-pharmacological treatments. Psychological interventions, including cognitive-behavioral therapy and pharmacotherapy, have shown promise in mitigating PTSD symptoms in ICU survivors. However, further research is needed to better understand the mechanisms underlying ICU-related PTSD and to develop targeted interventions to prevent and manage this debilitating condition.

Prevalence of and predictive factors associated with high levels of post-traumatic stress symptoms 3 months after intensive care unit admission: A prospective study

BACKGROUND

Post-traumatic stress symptoms (PTSS) following intensive care unit (ICU) treatment may increase morbidity and mortality. Therefore, it is important to identify patients at risk of suffering from such symptoms.

OBJECTIVES

The objective of this study was to describe the prevalence and identify possible predictive factors associated with high levels of PTSS 3 months after ICU admission.

METHODS

A multicentre, observational study was carried out in six ICUs in Norway. Patients aged ≥18 years were included. The Impact of Event Scale-Revised measured PTSS 3 months after ICU admission. The impacts of pre-ICU measures; demographic and clinical measures; and daily measures of pain, agitation, and delirium were analysed using univariate and multivariate logistic regression models.

RESULTS

In total, of the 273 patients included, the prevalence rate of high levels of PTSS was 19.8% (n = 54) 3 months after ICU admission (95% confidence interval [CI]: [15.2, 25.0]). Female gender, age, pre-ICU unemployment, a minimum of one episode of agitation or delirium, and pre-ICU level of functioning in daily living were all significantly associated with high levels of PTSS in univariate logistic analyses. In the multivariate logistic regression, two models were analysed. In model 1, episodes of agitation during ICU stay (odds ratio [OR] = 4.73; 95% CI: [1.17, 19.0]), pre-ICU unemployment (OR = 3.33; 95% CI: [1.26, 8.81]), and pre-ICU level of functioning in daily living (OR = 0.78; 95% CI: [0.63, 0.96]) (implying lower level) increased the odds of reporting high levels of PTSS. In model 2, pre-ICU unemployment (OR = 2.70; 95% CI: [1.05, 6.93]) and pre-ICU level of functioning in daily living (OR = 0.77; 95% CI: [0.62, 0.95]) (implying lower level) increased the odds of reporting high levels of PTSS.

CONCLUSIONS

Healthcare personnel are suggested to be aware of ICU patients' pre-ICU employment status, pre-ICU functioning in daily living, and agitation during ICU stay to identify those at risk of PTSS after discharge.

From bedside to recovery: exercise therapy for prevention of post-intensive care syndrome

BACKGROUND

As advancements in critical care medicine continue to improve Intensive Care Unit (ICU) survival rates, clinical and research attention is urgently shifting toward improving the quality of survival. Post-Intensive Care Syndrome (PICS) is a complex constellation of physical, cognitive, and mental dysfunctions that severely impact patients' lives after hospital discharge. This review provides a comprehensive and multi-dimensional summary of the current evidence and practice of exercise therapy (ET) during and after an ICU admission to prevent and manage the various domains of PICS. The review aims to elucidate the evidence of the mechanisms and effects of ET in ICU rehabilitation and highlight that suboptimal clinical and functional outcomes of ICU patients is a growing public health concern that needs to be urgently addressed.

MAIN BODY

This review commences with a brief overview of the current relationship between PICS and ET, describing the latest research on this topic. It subsequently summarises the use of ET in ICU, hospital wards, and post-hospital discharge, illuminating the problematic transition between these settings. The following chapters focus on the effects of ET on physical, cognitive, and mental function, detailing the multi-faceted biological and pathophysiological mechanisms of dysfunctions and the benefits of ET in all three domains. This is followed by a chapter focusing on co-interventions and how to maximise and enhance the effect of ET, outlining practical strategies for how to optimise the effectiveness of ET. The review next describes several emerging technologies that have been introduced/suggested to augment and support the provision of ET during and after ICU admission. Lastly, the review discusses future research directions.

CONCLUSION

PICS is a growing global healthcare concern. This review aims to guide clinicians, researchers, policymakers, and healthcare providers in utilising ET as a therapeutic and preventive measure for patients during and after an ICU admission to address this problem. An improved understanding of the effectiveness of ET and the clinical and research gaps that needs to be urgently addressed will greatly assist clinicians in their efforts to rehabilitate ICU survivors, improving patients' quality of survival and helping them return to their normal lives after hospital discharge.

Continuous infusion ketamine for sedation of mechanically ventilated adults in the intensive care unit: A scoping review

Introduction

Mechanical ventilation (MV) is a common and often live-saving intervention on the Intensive Care Unit (ICU). The optimisation of sedation to mechanical ventilation is fundamental, and inappropriate sedation has been associated with worse outcomes. This scoping review has been designed to answer the question 'What is known about the use of ketamine as a continuous infusion to provide sedation in mechanically ventilated adults in the intensive care unit, and what are the gaps in the evidence?'

Methods

The protocol was designed using the PRISMA-ScR checklist and the JBI manual for evidence synthesis. Data were extracted and reviewed by a minimum of two reviewers.

Results

Searches of electronic databases (PubMed, OVID, Scopus, Web of Science) produced 726 results; 45 citations were identified for further eligibility assessment, an additional five studies were identified through keyword searches, and 12 through searching reference lists. Of these 62 studies, 27 studies were included in the final review: 6 case reports/case series, 11 retrospective cohort/observational studies, 1 prospective cohort study, 9 prospective randomised studies.

Conclusion

We found a lack of high-quality well-designed studies investigating the use of continuous ketamine sedation on ICU. The available data suggests this intervention is safe and well tolerated, however this is of very low certainty given the poor quality of evidence.

Psychological impact of medical evacuation for ICU saturation in Covid-19-related ARDS patients

PURPOSE

Psychological impact of Medical Evacuation (MEDEVAC) in Covid-19 patients is undetermined. The objectives were to evaluate: Post-traumatic Stress Disorder (PTSD) in MEDEVAC patients hospitalized in ICU for Covid-19-related acute respiratory distress syndrome (ARDS) compared to control group; anxiety, depression rates and outcomes in patients and PTSD in relatives.

MATERIAL AND METHODS

This is a retrospective multicentric 1/1 paired cohort performed in 10 ICUs in the West of France. Evaluation was performed 18 months after discharge. Patients and closest relatives performed IES-R (Impact and Event Scale-Revised) and/or HADS (Hospital Anxiety and Depression Scale) scales.

RESULTS

Twenty-six patients were included in each group. Patients were 64 ± 11 years old, with 83% male. We report 12 vs 20% of PTSD in control vs MEDEVAC groups (p = 0.7). Anxiety disorder affected 43.5 vs 28.0% (p = 0.26) and depression 12.5 vs 14.3% (p > 0.99) in control vs MEDEVAC groups. PTSD affects 33.3 vs 42.1% of closest relatives (p = 0.55). Ways of communication were adapted: video calls were more frequent in MEDEVAC patients (8.7 vs 60.9%, p < 0.01) whereas physical visits concerned more control group (45.8 vs 13.0%, p = 0.01).

CONCLUSIONS

PTSD rate were similar between groups. Adaptive ways of communication, restricted visits and global uncertainties could explain the absence of differences.

Post-traumatic stress symptoms six months after ICU admission with COVID-19: Prospective observational study

AIMS AND OBJECTIVES

The aim of this study was to investigate the prevalence of post-traumatic stress symptoms, and to identify possible predictive factors in Norwegian intensive care unit survivors, 6 months after admission to the intensive care unit with COVID-19.

BACKGROUND

The SARS CoV-2 virus causing COVID-19 has spread worldwide since it was declared a pandemic in March 2020. The most severely ill patients have been treated in the intensive care due to acute respiratory failure and also acute respiratory distress syndrome. It is well documented that these severe conditions can lead to complex and long-lasting symptoms, such as psychological distress, and was, therefore, investigated for the specific COVID-19 population.

DESIGN

Prospective observational study.

METHODS

Clinical data and patient reported outcome measures were collected by the Norwegian Intensive Care and Pandemic Registry and by the study group 6 months after admission to an intensive care unit.

RESULTS

Among 222 COVID-19 patients admitted to Norwegian intensive care units between 10 March and 6 July 2020, 175 survived. The study sample consisted of 131 patients who responded to at least one patient reported outcome measure at 6 months following admission. The primary outcome was self-reported post-traumatic stress symptoms, using the Impact of Event Scale-6 (n = 89). Of those, 22.5% reported post-traumatic stress symptoms 6 months after admission. Female gender, younger age and having a high respiratory rate at admission were statistically significant predictive factors for reporting post-traumatic stress symptoms.

CONCLUSIONS

The result is in accordance with previously published research with comparable populations, suggesting that for many COVID-19 survivors psychological distress is a part of the post-acute sequelae. Results from the present study should be replicated in larger datasets.

RELEVANCE TO CLINICAL PRACTICE

This project provides important insight to post-acute sequelae after COVID-19 that patients may experience after critical illness.

Posttraumatic stress disorder symptoms in systemic autoimmune rheumatic disease patients during the early COVID-19 pandemic

AIM

Given reports of increased prevalence of PTSD symptoms at COVID-19 pandemic onset, we aimed to assess the prevalence of posttraumatic stress disorder (PTSD) symptoms at pandemic onset in individuals with and without systemic autoimmune rheumatic disease (SARD).

METHODS

In May 2020, we invited 6678 patients to complete the Brief Trauma Questionnaire and the Posttraumatic Stress Disorder Checklist (PCL-5), validated PTSD symptom screenings. We compared responses from patients with and without SARD using multivariable logistic regression.

RESULTS

We received 1473 responses (22% response rate) from 5/2020 to 9/2021 (63 with prior PTSD diagnoses, 138 with SARD history). The SARD population was more female (p .0001) and had a higher baseline prevalence of stress disorders (56% vs. 43%, p .004). SARD subjects reported more experiences with life-threatening illness, 60%, versus 53% among those without SARD (p .13), and more antidepressant or anxiolytic medication use pre-pandemic (78% vs. 59%, p .0001). Adjusting for pre-pandemic PTSD diagnosis, younger age and history of stress disorder were the most significant predictors of PCL-5 positivity. There were no significant differences in PCL-5 score or positivity among those with or without SARD.

CONCLUSION

In this population, patients with SARD had a higher pre-COVID-19 prevalence of stress-related conditions, but it was not the case that they had an increased risk of PTSD symptoms in the early pandemic. Younger individuals, those with baseline depression, anxiety, or adjustment disorders, and those taking antidepressant or anxiolytic medications were more likely to have PTSD symptoms in the first waves of the COVID-19 pandemic.

Half a Century of Research on Posttraumatic Stress Disorder: A Scientometric Analysis

We conducted a scientometric analysis to outline clinical research on posttraumatic stress disorder (PTSD). Our primary objective was to perform a broad-ranging scientometric analysis to evaluate key themes and trends over the past decades. Our secondary objective was to measure research network performance. We conducted a systematic search in the Web of Science Core Collection up to 15 August 2022 for publications on PTSD. We identified 42,170 publications published between 1945 and 2022. We used CiteSpace to retrieve the co-cited reference network (1978-2022) that presented significant modularity and mean silhouette scores, indicating highly credible clusters (Q = 0.915, S = 0.795). Four major trends of research were identified: 'war veterans and refugees', 'treatment of PTSD/neuroimaging', 'evidence syntheses', and 'somatic symptoms of PTSD'. The largest cluster of research concerned evidence synthesis for genetic predisposition and environmental exposures leading to PTSD occurrence. Research on war-related trauma has shifted from battlefield-related in-person exposure trauma to drone operator trauma and is being out published by civilian-related trauma research, such as the 'COVID-19' pandemic impact, 'postpartum', and 'grief disorder'. The focus on the most recent trends in the research revealed a burst in the 'treatment of PTSD' with the development of Mhealth, virtual reality, and psychedelic drugs. The collaboration networks reveal a central place for the USA research network, and although relatively isolated, a recent surge of publications from China was found. Compared to other psychiatric disorders, we found a lack of high-quality randomized controlled trials for pharmacological and nonpharmacological treatments. These results can inform funding agencies and future research.

Development and validation of a machine learning model using electronic health records to predict trauma- and stressor-related psychiatric disorders after hospitalization with sepsis

A significant minority of individuals develop trauma- and stressor-related disorders (TSRD) after surviving sepsis, a life-threatening immune response to infections. Accurate prediction of risk for TSRD can facilitate targeted early intervention strategies, but many existing models rely on research measures that are impractical to incorporate to standard emergency department workflows. To increase the feasibility of implementation, we developed models that predict TSRD in the year after survival from sepsis using only electronic health records from the hospitalization (n = 217,122 hospitalizations from 2012-2015). The optimal model was evaluated in a temporally independent prospective test sample (n = 128,783 hospitalizations from 2016-2017), where patients in the highest-risk decile accounted for nearly one-third of TSRD cases. Our approach demonstrates that risk for TSRD after sepsis can be stratified without additional assessment burden on clinicians and patients, which increases the likelihood of model implementation in hospital settings.

Advances in post intensive care unit care: A narrative review

As the treatment options, modalities and technology have grown, mortality in intensive care unit (ICU) has been on the decline. More and more patients are being discharged to wards and in the care of their loved ones after prolonged treatment at times and sometimes in isolation. These survivors have a lower life expectancy and a poorer quality of life. They can have substantial familial financial implications and an economic impact on the healthcare system in terms of increased and continued utilisation of services, the so-called post intensive care syndrome (PICS). But it is not only the patient who is the sufferer. The mental health of the loved ones and family members may also be affected, which is termed as PICS-family. In this review, we shall be reviewing the definition, epidemiology, clinical features, diagnosis and evaluation, treatment and follow up of PICS. We shall also focus on measures to prevent, rehabilitate and understand the ICU stay from patients’ perspective on how to redesign the ICU, post ICU care needs for a better patient outcome.

Changes in Restricting Symptoms after Critical Illness among Community-Living Older Adults

Rationale: Survivors of critical illness have multiple symptoms, but how restricting symptoms change after critical illness and whether these changes differ among vulnerable subgroups is unknown. Objectives: To evaluate changes in restricting symptoms over the six months after critical illness among older adults and to determine whether these changes differ by sex, multimorbidity, and individual- and neighborhood-level socioeconomic disadvantage. Methods: From a prospective longitudinal study of 754 community-living adults ⩾70 years old interviewed monthly (1998-2018), we identified 233 admissions from 193 participants to the ICU. The occurrence of 15 restricting symptoms, defined as those leading to restricted activity, were ascertained during interviews in the month before ICU admission (baseline) and each of the six months after hospital discharge. Measurements and Main Results: The occurrence and number of restricting symptoms increased more than threefold in the six months after a critical illness hospitalization (adjusted rate ratio [95% confidence interval], 3.1 [2.1-4.6] and 3.3 [2.1-5.3], respectively), relative to baseline. These increases were largest in the first month after hospitalization (adjusted rate ratio [95% confidence interval], 5.3 [3.8-7.3] and 5.4 [3.9-7.5], respectively] before declining and becoming nonsignificant in the third month. Increases in restricting symptoms did not differ significantly by sex, multimorbidity, or individual- or neighborhood-level socioeconomic disadvantage. Conclusions: Restricting symptoms increase substantially after a critical illness before returning to baseline three months after hospital discharge. Our findings highlight the need to incorporate symptom management into post-ICU care and for further investigation into whether addressing restricting symptoms can improve quality of life and functional recovery among older ICU survivors.

Piloting an ICU follow-up clinic to improve health-related quality of life in ICU survivors after a prolonged intensive care stay (PINA): feasibility of a pragmatic randomised controlled trial

BACKGROUND

ICU survivors often suffer from prolonged physical and mental impairments resulting in the so called "Post-Intensive Care Syndrome" (PICS). The aftercare of former ICU patients affected by PICS in particular has not been addressed sufficiently in Germany so far. The aim of this study was to evaluate the feasibility of a pragmatic randomised trial (RCT) comparing an intensive care unit (ICU) follow-up clinic intervention to usual care.

METHODS

This pilot study in a German university hospital evaluated the feasibility of a pragmatic RCT. Patients were assigned in a 1:1 ratio to an ICU follow-up clinic intervention or to usual care. The concept of this follow-up clinic was previously developed in a participatory process with patients, next of kin, health care professionals and researchers. We performed a process evaluation and determined acceptability, fidelity, completeness of measurement instruments and practicality as feasibility outcomes. The RCT's primary outcome (health-related quality of life) was assessed six months after ICU discharge by means of the physical component scale of the Short-Form-12 self-report questionnaire.

RESULTS

The pilot study was conducted from June 2020 to May 2021 with 21 and 20 participants in the intervention and control group. Principal findings related to feasibility were 85% consent rate (N = 48), 62% fidelity rate, 34% attrition rate (N = 41) and 77% completeness of outcome measurements. The primary effectiveness outcome (health-related quality of life) could be measured in 93% of participants who completed the study (N = 27). The majority of participants (85%) needed assistance with follow-up questionnaires (practicality). Median length of ICU stay was 13 days and 85% (N = 41) received mechanical ventilation, median Sequential Organ Failure Assessment Score was nine. Six-month follow-up assessment was planned for all study participants and performed for 66% (N = 41) of the participants after 197 days (median).

CONCLUSION

The participatory developed intervention of an ICU follow-up clinic and the pragmatic pilot RCT both seem to be feasible. We recommend to start a pragmatic RCT on the effectiveness of the ICU follow-up clinic.

TRIAL REGISTRATION

ClinicalTrials.gov US NLM, NCT04186468, Submission: 02/12/2019, Registration: 04/12/2019, https://clinicaltrials.gov/ct2/show/NCT04186468.

"I Am Not the Same as I Was Before": A Qualitative Analysis of COVID-19 Survivors

BACKGROUND

Little is known about the illness experience of patients' long-term emotional and physical recovery from severe COVID-19 infection. This study aimed to expand upon the recovery process of COVID-19 survivors up to 6 months after hospital discharge.

METHODS

Qualitative analysis of free-response answers from a cohort study of 152 patients ≥ 18 years hospitalized with laboratory-confirmed SARS-CoV-2 surveyed at 1-month post hospital discharge and 6-months post hospital discharge. Responses were analyzed with a grounded theory approach to identify overarching themes.

RESULTS

Participants described persistent complications, both physical and mental, that have affected their recovery from COVID-19. Five overarching themes of post-acute patient experiences were generated: (1) an increased awareness of a mind and body connection, (2) feelings of premature aging, (3) an overall decline in quality of life, (4) a continued fear of infection, and (5) methods of coping.

CONCLUSIONS

Patients described lasting changes to their mental health and overall quality of life in connection to physical complications after severe COVID-19 infection. Patients' reports of their experience call for a greater awareness of the psychological aspects of COVID-19 recovery to provide both physical and psychological rehabilitation services. Additional resources such as education around re-infection and financial resources are needed.

The Impact of an Intensive Care Diary on the Psychological Well-Being of Patients and Their Family Members: Longitudinal Study Protocol

BACKGROUND

Thanks to medical and technological advancements, an increasing number of individuals survive admission to intensive care units. However, survivors often experience negative outcomes, including physical impairments and alterations in mental health. Anxiety, depression, cognitive impairments, post-traumatic stress disorders, and functional disorders are known collectively as post-intensive care syndrome (PICS). Among the key triggering factors of this syndrome, memory impairment appears to play a significant role.

AIMS

This study aims to evaluate the impact of an intensive care diary on the psychological well-being of patients and their relatives after discharge from the ICU.

DESIGN

Prospective observational study.

EXPECTED RESULTS

The results of this study evaluate the impact of an ICU diary on the quality of life of ICU survivors and their family members.

Quality of life after extra corporeal life support therapy

BACKGROUND

Extra Corporeal Life Support (ECLS) may be a life-saving treatment for patients with reversible cardiac and/or respiratory failure. ECLS is associated with a high risk of complications and mortality. Because only a small number of studies have been conducted into the long-term effects of ECLS, we investigated the difference in quality of life, anxiety and depressive complaints and PTSD 3 months after ICU discharge.

METHOD

It is a retrospective case-control study covering the period January 2012 to December 2017. The ECLS patient group was compared to a matched similar patient group in the Intensive Care (IC) that did not have ECLS therapy. Quality of life was measured with the Short-Form-36 (SF-36) questionnaire, anxiety and depression was measured with the Hospital Anxiety and Depression Scale (HADS) questionnaire and for PTSD the Impact of Events Scale (IES) questionnaire was used, comparing sum scores and cut-off points of scores from both groups.

RESULTS

Included were 19 patients in the ECLS group and 38 in the control group. The mean sum scores on the sub scales of the SF36 questionnaire were the same for both groups. Only the mean score of 66.2 (scale 0-100) on the domain 'general health experience' was statistically significantly different in the ECLS group than in the control group (56.8, p = .02). There was no significant difference between the sum scores of both groups on anxiety and depressive complaints. In the ECLS group 32% of the patients may have a depressive disorder versus 18% from the control group (p = .32). And 26% of the patients from the ECLS group may have an anxiety disorder versus 7% from the control group (p = .51). The incidence of PTSD was 42% in the ECLS group and 24% in the control group (p = .22).

CONCLUSION

We found no statistically significant difference in quality of life, anxiety and depressive symptoms and PTSD symptoms between ECLS patients and the matched control group - 3 months after the ICU discharge. The incidence of anxiety and depressive symptoms and PTSD in the ECLS group is higher than in the control group, however, this difference is not significant.

Pressure Ulcer Patients' Psychological Understanding of Nursing Care Received in Intensive Care Unit

INTRODUCTION

Awareness of the perceptions of patients regarding the nursing services provided during hospitalization can enhance the quality and safety of nursing care. The objective of this study was to elucidate the psychological perceptions of patients with bedsores regarding the nursing care they received in the intensive care unit.

METHOD

This descriptive qualitative study was conducted in 2021. The study population comprised patients admitted to the cardiac intensive care units of Chamran Hospital in Isfahan, Iran. The sample included 10 patients who fulfilled the inclusion criteria. These patients were selected using a purposive sampling technique. Semi-structured interviews were employed for data collection. Sampling continued until data saturation was reached. Data were analyzed using conventional qualitative content analysis.

RESULTS

In this study, the codes obtained were classified into 10 subcategories, which were subsequently merged into three main categories. The main categories included "neglected wound care", "empathetic care", and "patient hope and trust".

CONCLUSION

The findings of this study revealed that the psychological understanding of patients with bedsores was associated with numerous components and challenges that necessitate the attention and consideration of nurses during the provision of care to these patients.

A randomised pilot feasibility study of eye movement desensitisation and reprocessing recent traumatic episode protocol, to improve psychological recovery following intensive care admission for COVID-19

Background

Approximately 50% of intensive care survivors experience persistent psychological symptoms. Eye-movement desensitisation and reprocessing (EMDR) is a widely recommended trauma-focussed psychological therapy, which has not been investigated systematically in a cohort of intensive care survivors: We therefore conducted a randomised pilot feasibility study of EMDR, using the Recent Traumatic Episode Protocol (R-TEP), to prevent psychological distress in intensive care survivors. Findings will determine whether it would be possible to conduct a fully-powered clinical effectiveness trial and inform trial design.

Method

We aimed to recruit 26 patients who had been admitted to intensive care for over 24 h with COVID-19 infection. Consenting participants were randomised (1:1) to receive either usual care plus remotely delivered EMDR R-TEP or usual care alone (controls). The primary outcome was feasibility. We also report factors related to safety and symptom changes in post-traumatic stress disorder, (PTSD) anxiety and depression.

Results

We approached 51 eligible patients, with 26 (51%) providing consent. Intervention adherence (sessions offered/sessions completed) was 83%, and 23/26 participants completed all study procedures. There were no attributable adverse events. Between baseline and 6-month follow-up, mean change in PTSD score was -8 (SD = 10.5) in the intervention group versus +0.75 (SD = 15.2) in controls (p = 0.126). There were no significant changes to anxiety or depression.

Conclusion

Remotely delivered EMDR R-TEP met pre-determined feasibility and safety objectives. Whilst we achieved group separation in PTSD symptom change, we have identified a number of protocol refinements that would improve the design of a fully powered, multi-centre randomised controlled trial, consistent with currently recommended rehabilitation clinical pathways.

Trial registration

ClinicalTrials.gov: NCT04455360.

Staff perspectives on the influence of patient characteristics on alarm management in the intensive care unit: a cross-sectional survey study

BACKGROUND

High rates of clinical alarms in the intensive care unit can result in alarm fatigue among staff. Individualization of alarm thresholds is regarded as one measure to reduce non-actionable alarms. The aim of this study was to investigate staff's perceptions of alarm threshold individualization according to patient characteristics and disease status.

METHODS

This is a cross-sectional survey study (February-July 2020). Intensive care nurses and physicians were sampled by convenience. Data was collected using an online questionnaire.

RESULTS

Staff view the individualization of alarm thresholds in the monitoring of vital signs as important. The extent to which alarm thresholds are adapted from the normal range varies depending on the vital sign monitored, the reason for clinical deterioration, and the professional group asked. Vital signs used for hemodynamic monitoring (heart rate and blood pressure) were most subject to alarm individualizations. Staff are ambivalent regarding the integration of novel technological features into alarm management.

CONCLUSIONS

All relevant stakeholders, including clinicians, hospital management, and industry, must collaborate to establish a "standard for individualization," moving away from ad hoc alarm management to an intelligent, data-driven alarm management. Making alarms meaningful and trustworthy again has the potential to mitigate alarm fatigue - a major cause of stress in clinical staff and considerable hazard to patient safety.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (NCT03514173) on 02/05/2018.

Neuropsychiatric Outcomes in Intensive Care Unit Survivors

BACKGROUND

Over the last two decades, there has been phenomenal advancement in critical care medicine and patient management. Many patients recover from life-threatening illnesses that they might not have survived a decade ago. Despite a decrease in mortality, these survivors endure long-lasting sequelae like physical, mental, and emotional symptoms.

METHODS

Patients after intensive care unit (ICU) discharge were assessed in a follow-up outpatient department (OPD) clinic for anxiety, stress, and depression. Patients were asked to fill out the questionnaires Depression, Anxiety and Stress Scale-21 (DASS-21) and Short Form-36 (SF-36) for assessment of health-related quality of life (HRQOL) at 4th, 6th, and 8th months after discharge. ICU data were recorded, including patients' demographics, severity of illness and length of stay, and duration of mechanical ventilation. Patients who failed to follow-up in OPD on designated dates were assessed telephonically.

RESULTS

Depression showed a positive, strong, and moderate correlation between length of stay and mechanical ventilation duration. A positive correlation was found between stress and length of stay and duration of mechanical ventilation. A positive strong correlation was found between anxiety and length of ICU stay, and a moderate positive correlation was found between anxiety and duration of mechanical ventilation. A weak correlation was found between age and neuropsychiatric outcomes.

CONCLUSION

The severity of depression, anxiety, and stress was significantly higher at four months compared to six months. Severity decreased with time. Prolonged ICU stay increased levels of anxiety, depression, and stress. HRQOL improved from four to six months.

Prospective single-center study of health-related quality of life after COVID-19 in ICU and non-ICU patients

Long-term sequelae in hospitalized Coronavirus Disease 2019 (COVID-19) patients may result in limited quality of life. The current study aimed to determine health-related quality of life (HRQoL) after COVID-19 hospitalization in non-intensive care unit (ICU) and ICU patients. This is a single-center study at the University Hospital of Wuerzburg, Germany. Patients eligible were hospitalized with COVID-19 between March 2020 and December 2020. Patients were interviewed 3 and 12 months after hospital discharge. Questionnaires included the European Quality of Life 5 Dimensions 5 Level (EQ-5D-5L), patient health questionnaire-9 (PHQ-9), the generalized anxiety disorder 7 scale (GAD-7), FACIT fatigue scale, perceived stress scale (PSS-10) and posttraumatic symptom scale 10 (PTSS-10). 85 patients were included in the study. The EQ5D-5L-Index significantly differed between non-ICU (0.78 ± 0.33 and 0.84 ± 0.23) and ICU (0.71 ± 0.27; 0.74 ± 0.2) patients after 3- and 12-months. Of non-ICU 87% and 80% of ICU survivors lived at home without support after 12 months. One-third of ICU and half of the non-ICU patients returned to work. A higher percentage of ICU patients was limited in their activities of daily living compared to non-ICU patients. Depression and fatigue were present in one fifth of the ICU patients. Stress levels remained high with only 24% of non-ICU and 3% of ICU patients (p = 0.0186) having low perceived stress. Posttraumatic symptoms were present in 5% of non-ICU and 10% of ICU patients. HRQoL is limited in COVID-19 ICU patients 3- and 12-months post COVID-19 hospitalization, with significantly less improvement at 12-months compared to non-ICU patients. Mental disorders were common highlighting the complexity of post-COVID-19 symptoms as well as the necessity to educate patients and primary care providers about monitoring mental well-being post COVID-19.

Incidence, Risk Factors, and Consequences of Post-Traumatic Stress Disorder Symptoms in Survivors of COVID-19-Related ARDS

Purpose: To assess the prevalence of symptoms of Post-Traumatic Stress Disorder (PTSD) in survivors of COVID-19 Acute Respiratory Distress Syndrome that needed ICU care; to investigate risk factors and their impact on the Health-Related Quality of life (HR-QoL). Materials and Methods: This multicenter, prospective, observational study included all patients who were discharged from the ICU. Patients were administered the European Quality of Life 5 Dimensions 5 Level Version (EQ-5D-5L) questionnaire, the Short-Form Health Survey 36Version 2 (SF-36v2), a socioeconomic question set and the Impact of Event Scale-Revised (IES-R) to assess PTSD. Results: The multivariate logistic regression model found that an International Standard Classification of Education Score (ISCED) higher than 2 (OR 3.42 (95% CI 1.28-9.85)), monthly income less than EUR 1500 (OR 0.36 (95% CI 0.13-0.97)), and more than two comorbidities (OR 4.62 (95% CI 1.33-16.88)) are risk factors for developing PTSD symptoms. Patients with PTSD symptoms are more likely to present a worsening in their quality of life as assessed by EQ-5D-5L and SF-36 scales. Conclusion: The main factors associated with the development of PTSD-related symptoms were a higher education level, a lower monthly income, and more than two comorbidities. Patients who developed symptoms of PTSD reported a significantly lower Health-Related Quality of life as compared to patients without PTSD. Future research areas should be oriented toward recognizing potential psychosocial and psychopathological variables capable of influencing the quality of life of patients discharged from the intensive care unit to better recognize the prognosis and longtime effects of diseases.

Post Hospital Discharge Functional Recovery of Critical Illness Survivors. Systematic Review

Background

Millions of people face critical illnesses and need to be hospitalized in an Intensive Care Unit (ICU) annually worldwide. Despite the fact that survival rates of these patients have increased, they develop various cognitive, psychological and functional impairments. This study aims to investigate the significance of the recovery interventions following intensive care unit discharge, the effectiveness of the rehabilitative protocols and their possible deficits.

Methods

MEDLINE (PubMed) and Physiotherapy Evidence Database (PEDro) were searched for studies analyzing the recovery potentials post-ICU among adults, who spent at least 48 hours at the ICU. Methodological quality of the studies was assessed via PEDro Scale.

Results

Nine randomized controlled trials were included. These took place mainly at specialized rehabilitation gyms as well as patients home environments. Studies analyses showed that treatment group showed improvement in functional ability in relation to control group. Nevertheless, differences between two groups were not statistically significant (P<0.05). The majority of studies assessed cardiorespiratory endurance and muscular strength.

Conclusions

The included rehabilitation programs were determined to be effective. Although they didn't prove any statistically significant difference between groups, quality of life enhancements and stress reduction were reported. Hence, new randomized controlled trials are required in order to provide more accurate data on the potential benefits of rehabilitation strategies among post-ICU patients.