Risk factors for depression and anxiety in survivors of acute respiratory distress syndrome

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.

Long-term outcomes of patients supported with extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is increasingly used to support patients with severe acute respiratory distress syndrome (ARDS). The impact of ECMO on long-term outcomes of patients with severe ARDS is unclear.

METHODS

We searched electronic databases from inception to January 17th 2023. We selected clinical trials and observational studies reporting on long-term outcomes of patients supported with ECMO for ARDS. Health-related quality of life (HRQoL) was the primary outcome. Secondary outcomes included cognitive function, mental health, functional status, respiratory symptoms, and return to work.

RESULTS

Of the 7126 screened citations, 1 randomized clinical trial and 31 observational studies were included, of which 7 compared conventional mechanical ventilation (CMV) and ECMO. Overall quality of studies of the included studies was limited, with the majority being either low (45%) or fair (32%) quality. There was no significant difference in HRQoL measured with the SF-36 score between ECMO and CMV patients (physical component score [PCS]: mean difference 3.91 (- 6.22 to 14.05), mental component score [MCS] mean difference 1.33 (- 3.93 to 6.60)). There was no difference between cognitive function, mental health, functional status, and respiratory symptoms between ECMO and CMV, but data available for comparison were limited. There were high rates of disability for ECMO survivors with 49% of patients returning to work and 23% needing assistance at home on follow-up.

CONCLUSION

Survivors of ECMO for ARDS experience significant disability in multiple domains. Further studies are needed to examine the effect of ECMO on long-term outcomes of patients compared to CMV.

Cognitive Impairment, Physical Impairment, and Psychological Symptoms in Intensive Care Unit Survivors

BACKGROUND

Post-intensive care syndrome (PICS) affects 25% to 50% of adults who survive an intensive care unit (ICU) stay. Although the compounding of PICS impairments (cognitive, physical, and psychological) could intensify the syndrome, research on relationships among impairments is limited, particularly in patients with delirium.

OBJECTIVES

To examine associations among PICS impairments and examine delirium status and its relationship to PICS impairments at ICU discharge and 1 month later.

METHODS

A descriptive, correlational study of adults who survived an ICU stay. Participants completed measures for depression, anxiety, posttraumatic stress, physical function, functional status, and cognition at ICU discharge and 1 month later. Relationships among PICS impairments were examined with Spearman correlations; differences in impairments by delirium status were assessed with t tests.

RESULTS

Of 50 enrolled participants, 46 were screened for PICS impairment at ICU discharge and 35 were screened 1 month later. Cognitive impairment was the most common impairment at both time points. A positive correlation was found between cognition and functional status at ICU discharge (ρ = 0.50, P = .001) and 1 month later (ρ = 0.54, P = .001). Cognition and physical functioning were positively correlated 1 month after discharge (ρ = 0.46, P = .006). The group with delirium had significantly lower functional status scores than the group without delirium at ICU discharge (P = .04).

CONCLUSIONS

The findings suggest a moderate correlation between cognitive and physical impairments. This relationship should be explored further; ICU survivors with undiagnosed cognitive impairment may have delayed physical recovery and greater risk for injury.

[Aftercare of ICU patients: A task for pneumology?]

As the number of patients treated in intensive care medicine increases, so does the number of those who suffer from the long-term consequences of critical illness and the consequences of a stay in an intensive care unit. For this group of patients with a post-intensive care syndrome (PICS), there are currently no specialized outpatient care structures that follow the hospital stay and possible follow-up treatment. A number of studies are researching the effectiveness of intensive care outpatient clinics nationally and internationally.After presenting the PICS and the associated complex need for care, this review article presents various model projects for outpatient follow-up care of critically ill patients. We discuss whether the field of pneumology is particularly suitable for the study of therapy control of complex clinical pictures since it has vast experience in the treatment of intensive care patients and the outpatient care of chronically ill patients.

Higher intraoperative mean arterial blood pressure does not reduce postoperative delirium in elderly patients following gastrointestinal surgery: A prospective randomized controlled trial

BACKGROUND

This study aimed to describe the relationship between the different levels of intraoperative mean arterial blood pressure (MAP) and postoperative delirium in elderly patients undergoing gastrointestinal laparoscopic surgery.

MATERIALS AND METHODS

This prospective controlled clinical trial enrolled 116 patients aged 65 to 85 years who underwent gastrointestinal laparoscopic surgery. These patients were randomized 1:1 to a MAP goal of 65 to 85 mmHg (L group) or an 86 to 100 mmHg (H group). The primary endpoint was the incidence of postoperative delirium, assessed twice daily with the Confusion Assessment Method (CAM) and Richmond Agitation-Sedation Scale (RASS) during the first five postoperative days. Delirium severity was evaluated with the Delirium-O-Meter (D-O-M).

RESULTS

108 patients (L group n = 55, H group n = 53) were eventually included in intention-to-treat analyses. Postoperative delirium occurred in 18 (32.7%) of 55 cases of L group and in 15 (28.3%) of 53 cases of H group. The incidence of delirium subtypes between the two groups: hypoactive delirium 14.5% (8/55) vs 11.3% (6/53); hyperactive delirium 7.3% (4/55) vs 3.8% (2/53); mixed delirium 10.9% (6/55) vs 13.2% (7/53). However, the L group showed higher D-O-M scores of the first episode of delirium: 14.5 (Q1 = 12, Q3 = 18.5) vs 12 (Q1 = 10, Q3 = 14), which means the delirium is more severe.

CONCLUSIONS

Compared with 65 to 85 mmHg, maintaining intraoperative MAP at 86-100 mmHg did not reduce the incidence of postoperative delirium in elderly patients undergoing gastrointestinal laparoscopic surgery. However, the severity of delirium could be reduced and blood loss is a risk factor for postoperative delirium.

Prevalence and Risk Factor Analysis of Post-Intensive Care Syndrome in Patients with COVID-19 Requiring Mechanical Ventilation: A Multicenter Prospective Observational Study

Introduction: Post-intensive care syndrome (PICS) is an emerging problem in critically ill patients and the prevalence and risk factors are unclear in patients with severe coronavirus disease 2019 (COVID-19). This multicenter prospective observational study aimed to investigate the prevalence and risk factors of PICS in ventilated patients with COVID-19 after ICU discharge. Methods: Questionnaires were administered twice in surviving patients with COVID-19 who had required mechanical ventilation, concerning Barthel Index, Short-Memory Questionnaire, and Hospital Anxiety and Depression Scale scores. The risk factors for PICS were examined using a multivariate logistic regression analysis. Results: The first and second PICS surveys were obtained at 5.5 and 13.5 months (mean) after ICU discharge, with 251 and 209 patients completing the questionnaires and with a prevalence of PICS of 58.6% and 60.8%, respectively, along with the highest percentages of cognitive impairment. Delirium (with an odds ratio of (OR) 2.34, 95% CI 1.1–4.9, and p = 0.03) and the duration of mechanical ventilation (with an OR of 1.29, 95% CI 1.05–1.58, and p = 0.02) were independently identified as the risk factors for PICS in the first PICS survey. Conclusion: Approximately 60% of the ventilated patients with COVID-19 experienced persistent PICS, especially delirium, and required longer mechanical ventilation.

Effectiveness of Nurse-Led Interventions for the Prevention of Mental Health Issues in Patients Leaving Intensive Care: A Systematic Review

This study aimed to evaluate the effectiveness of nurse-led interventions for the prevention of mental health disorders after intensive care unit discharge through a systematic review of the literature. The searches were conducted in the MEDLINE (via PubMed), CINAHL, PsycINFO, and Cochrane Library databases for studies pertaining to such interventions. Two independent reviewers analyzed the studies, extracted data, and assessed the quality of the evidence. Six eligible articles were identified, all of which were regarding post-traumatic stress disorder after intensive care unit discharge. Some of the interventions were conducted during the admission and some after the discharge. One study found that multimedia education during admission improved anxiety and depression one week after discharge. The remaining five studies concluded that nurse-led interventions did not prevent mental health disorders three months to one year after intensive care unit discharge. Our review revealed a paucity of research into the effectiveness of nurse-led interventions for the prevention of mental health disorders after intensive care unit discharge. The timing and the content of these interventions, and the adequate training of nurses, appear to be key factors. Therefore, multidisciplinary interventions are likely to be more effective than those led by nurses alone.

Prevalence and Long-Term Prognosis of Post-Intensive Care Syndrome after Sepsis: A Single-Center Prospective Observational Study

Post-intensive care syndrome (PICS) comprises physical, mental, and cognitive disorders following a severe illness. The impact of PICS on long-term prognosis has not been fully investigated. This study aimed to: (1) clarify the frequency and clinical characteristics of PICS in sepsis patients and (2) explore the relationship between PICS occurrence and 2-year survival. Patients with sepsis admitted to intensive care unit were enrolled. Data on patient background; clinical information since admission; physical, mental, and cognitive impairments at 3-, 6-, and 12-months post-sepsis onset; 2-year survival; and cause of death were obtained from electronic medical records and telephonic interviews with patients and their families. At 3 months, comparisons of variables were undertaken in the PICS group and the non-PICS group. Among the 77 participants, the in-hospital mortality rate was 11% and the 2-year mortality rate was 52%. The frequencies of PICS at 3, 6, and 12 months were 70%, 60%, and 35%, respectively. The 2-year survival was lower in the PICS group than in the non-PICS group (54% vs. 94%, p < 0.01). More than half of the survivors had PICS at 3 and 6 months after sepsis. Among survivors with sepsis, those who developed PICS after 3 months had a lower 2-year survival.

Survivorship After Critical Illness and Post-Intensive Care Syndrome

Improvements in critical care medicine have led to a marked increase in survivors of the intensive care unit (ICU). These survivors encounter many difficulties following ICU discharge. The term post -intensive care syndrome (PICS) provides a framework for identifying the most common symptoms which fall into three domains: cognitive, physical, and mental health. There are numerous risk factors for the development of PICS including premorbid conditions and specific elements of ICU hospitalizations. Management is complex and should take an individualized approach with interdisciplinary care. Future research should focus on prevention, identification, and treatment of this unique population.

ARDS associated acute brain injury: from the lung to the brain

A complex interrelation between lung and brain in patients with acute lung injury (ALI) has been established by experimental and clinical studies during the last decades. Although, acute brain injury represents one of the most common insufficiencies in patients with ALI and acute respiratory distress syndrome (ARDS), the underlying pathophysiology of the observed crosstalk remains poorly understood due to its complexity. Specifically, it involves numerous pathophysiological parameters such as hypoxemia, neurological adverse events of lung protective ventilation, hypotension, disruption of the BBB, and neuroinflammation in such a manner that the brain of ARDS patients-especially hippocampus-becomes very vulnerable to develop secondary lung-mediated acute brain injury. A protective ventilator strategy could reduce or even minimize further systemic release of inflammatory mediators and thus maintain brain homeostasis. On the other hand, mechanical ventilation with low tidal volumes may lead to self-inflicted lung injury, hypercapnia and subsequent cerebral vasodilatation, increased cerebral blood flow, and intracranial hypertension. Therefore, by describing the pathophysiology of ARDS-associated acute brain injury we aim to highlight and discuss the possible influence of mechanical ventilation on ALI-associated acute brain injury.

Cognitive impairment in people with previous COVID-19 infection: A scoping review

Severe acute respiratory syndrome coronavirus 2 is a worldwide public health issue. Almost 2 years into the pandemic, the persistence of symptoms after the acute phase is a well-recognized phenomenon. We conducted a scoping review to map cognitive domain impairments, their frequency, and associated psycho-affective disorders in people with a previous COVID-19 infection. We searched PubMed/MEDLINE, Scopus, and PsycInfo to identify relevant reports published between December 1, 2019 and February 21, 2022. We followed the PRISMA (Preferred-Reporting-Items-for-Systematic-Reviews-and-Meta-Analyses) extension for scoping review guidelines. Three independent reviewers selected and charted 25 records out of 922. Memory, attention, and executive functions appeared to be the most affected domains. Delayed recall and learning were the most impaired domains of memory. Among the executive functions, abstraction, inhibition, set shifting, and sustained and selective attention were most commonly impaired. Language and visuo-spatial abilities were rarely affected, although this finding might be biased by the scarcity of reports. Neurological and respiratory conditions were often reported in association with cognitive deficits. Results on psycho-affective conditions were inconclusive due to the low frequency of reported data. Admission to an intensive care unit is not related to cognitive deficits. This review highlighted a potential effect of a previous post-COVID-19 infection on a pattern of memory, attention, and executive functions impairments. These findings need to be confirmed on larger cohorts with comprehensive neuropsychological batteries and correlated to neurophysiological and neurobiological substrates.

"A story with gaps": An interpretative phenomenological analysis of ICU survivors' experience

ICU survivors may experience various long-term sequelae, recognized as Post-Intensive Care Syndrome, that includes psychiatric symptoms: anxiety, depression, and post-traumatic stress disorders symptoms (PTSD). While it was hypothesized that an ICU diary could help patients after discharge, improving their hospitalization memories and quality of life, it is unclear whether it may reduce psychiatric disorders, in particular PTSD. We performed a qualitative exploration of survivors' subjective experience of their ICU stay, their representations, memories, meaning-making of their experience and use of their ICU diary. Five participants (ICU survivors, 3 men and 2 women, who received a diary) were included in this study. We conducted non-directive interviews 6 months after discharge. These interviews were transcribed and analyzed using Interpretative Phenomenological Analysis. Major recurring themes of discourse included: (1) The nightmare of the ICU experience: from an impression of vagueness to dispossession, (2) The positive image of health-care workers during intensive care, (3) The place of the relatives and health-care workers' writings in the diary: either a support or a barrier, (4) The difficult return back home, and daily life after intensive care. Participant's representation of their ICU experience seemed to reflect the meaning they had given it through their own reflections and that of health-care workers in the diary. For some participant, the diary was associated to the pain and strangeness of the ICU experience; therefore, their recovery required them to take some distance with it. The ICU diary allowed participants to construct their illness narratives, and to become aware of the presence and support of health-care workers. The diary was also perceived as the witness of a period they wished to forget. Trial registration: NCT02519725.

Post-Intensive Care Syndrome in Survivors from Critical Illness including COVID-19 Patients: A Narrative Review

Current achievements in medical science and technological advancements in intensive care medicine have allowed better support of critically ill patients in intensive care units (ICUs) and have increased survival probability. Post-intensive care syndrome (PICS) is a relatively new term introduced almost 10 years ago, defined as "new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization". A significant percentage of critically ill patients suffer from PICS for a prolonged period of time, with physical problems being the most common. The exact prevalence of PICS is unknown, and many risk factors have been described well. Coronavirus disease 2019 (COVID-19) survivors seem to be at especially high risk for developing PICS. The families of ICU survivors can also be affected as a response to the stress suffered during the critical illness of their kin. This separate entity is described as PICS family (PICS-F). A multidisciplinary approach is warranted for the treatment of PICS, involving healthcare professionals, clinicians, and scientists from different areas. Improving outcomes is both challenging and imperative for the critical care community. The review of the relevant literature and the study of the physical, cognitive, and mental sequelae could lead to the prevention and timely management of PICS and the subsequent improvement of the quality of life for ICU survivors.

Depression and mortality among survivors of acute respiratory distress syndrome in South Korea: A nationwide cohort study conducted from 2010 to 2018

It has been reported that survivors of acute respiratory distress syndrome (ARDS) experience depression. However, the relationship between newly developed depression and mortality among survivors of ARDS has not been elucidated. Thus, the aim of this study was to investigate the prevalence and associated factors of depression among survivors of ARDS and determine whether newly developed depression is associated with long-term mortality among them. The data used for this study were extracted from the national health insurance database of South Korea. All adult patients who were admitted into intensive care units for ARDS between January 1, 2010, and December 31, 2018, and survived for ≥1 year after treatment were defined as ARDS survivors and included in this study. A total of 4,452 ARDS survivors were included in the final analysis. Of these, 581 (13.4%) were newly diagnosed with depression within 1 year after ARDS diagnosis. Multivariable logistic regression showed that underlying anxiety disorder (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.93-2.86; P < 0.001), substance abuse (OR, 2.18; 95% CI, 1.48-3.20; P < 0.001), and post-traumatic stress disorder (OR, 15.52; 95% CI, 2.57-93.51; P = 0.003) were associated with a higher prevalence of post-ARDS depression among survivors. Multivariable Cox regression analysis showed that post-ARDS depression was associated with a 1.49-fold increased risk of 2-year all-cause mortality (hazard ratio, 1.49; 95% CI, 1.18-1.88; P = 0.001). Underlying psychiatric illness is a potential risk factor for the development of depression among ARDS survivors. Post-ARDS depression is associated with an increased risk of 2-year all-cause mortality.

Occurrence and Long-term Prognosis of Insomnia Disorder among Survivors of Acute Respiratory Distress Syndrome in South Korea

RATIONALE

As a most common type of sleep disorder, insomnia disorder can develop as a sequela among acute respiratory distress syndrome (ARDS) survivors. However, insomnia prevalence, its associated factors, and its impact on long-term survival remain controversial.

OBJECTIVES

This study aimed to investigate insomnia prevalence and its associated factors among ARDS survivors. We also examined the association between insomnia and 2-year all-cause mortality.

METHODS

The National Health Insurance Database of South Korea was used for this nationwide cohort study. We included adult patients (≥18 years old) admitted to intensive care units for ARDS treatment from January 1, 2010, to December 31, 2018, and survived for ≥1 year after diagnosis, defined as ARDS survivors. ARDS survivors diagnosed with insomnia disorder before ARDS diagnosis were defined as the pre-ARDS insomnia disorder group, whereas those who had no history of insomnia disorder but were newly diagnosed with insomnia disorder within 1 year of diagnosis of ARDS were defined as the post-ARDS insomnia disorder group.

RESULTS

A total of 4,452 ARDS survivors were included in this study, with 895 patients (20.1%) in the pre-ARDS insomnia disorder group and 536 (12.6%) patients in the post-ARDS insomnia disorder group. In the multivariable logistic regression analysis, delirium occurrence (odds ratio [OR]:1.61, 95% confidence interval [CI]: 1.24-2.10; P<0.001), underlying anxiety disorder (OR:1.34, 95% CI: 1.08-1.66; P=0.007), depression (OR: 1.48, 95% CI: 1.17-1.86; P=0.001), and substance abuse (OR:1.51, 95% CI: 1.01-2.26; P=0.042) were associated with a higher prevalence of post-ARDS insomnia disorder. In multivariable Cox regression analysis, the pre-ARDS insomnia disorder and post-ARDS insomnia disorder groups were associated with 1.33-fold (hazard ratio [HR]:1.33, 95% CI: 1.08-1.64; P=0.007) and 1.36-fold (HR:1.36, 95% CI: 1.06-1.74; P=0.016) increased prevalence of 2-year all-cause mortality among ARDS survivors, respectively.

CONCLUSIONS

At 1 year after diagnosis of ARDS, 12.6% of ARDS survivors were newly diagnosed with insomnia disorder in South Korea. Delirium and underlying psychiatric illness (anxiety disorder, depression, and substance abuse) were potential risk factors for the diagnosis of post-ARDS insomnia disorder. Moreover, both pre-and post-ARDS insomnia disorders were associated with 2-year all-cause mortality among ARDS survivors.

Presentation and management of anxiety in individuals with acute symptomatic or asymptomatic COVID-19 infection, and in the post-COVID-19 recovery phase

COVID-19 is associated with neuropsychiatric complications, the most frequent one being anxiety. Multiple biological and psychosocial factors contribute to anxiety in COVID-19. Among the biological factors, stress, genetics, gender, immune system, resilience, anosmia, hypogeusia, and central nervous system infection with SARS-CoV-2 are key. Anxiety is a complication of COVID-19 that may exacerbate the infection course, and the infection may exacerbate anxiety. We present the mechanisms of anxiety in symptomatic or asymptomatic COVID-19. We discuss the presentation of anxiety in patients without or with prior psychiatric illness, and with co-morbidities. Timely diagnosis and management of anxiety in COVID-19 patients is important. Given the frequent complication of COVID-19 with Acute Respiratory Distress Syndrome and Intensive Care Unit stay, anxiety may be a long-term complication. We review the diagnostic tools for anxiety in COVID-19, and summarise pharmacologic and non-pharmacologic treatments. We provide recommendations for diagnosis, treatment, prevention and follow up of anxiety in COVID-19.Key pointsPatients with COVID-19 (symptomatic or asymptomatic) exhibit a high frequency of neuropsychiatric complications with highest percentage attributed to anxiety.Multiple biological and psychosocial risk factors for anxiety exist in COVID-19-ill individuals. Biological risk factors include stress, resilience, genetics, gender, age, immune system, direct infection of the central nervous system (CNS) with SARS-CoV-2, comorbid psychiatric and general medical illnesses, ARDS and ICU stay. Anosmia and hypogeusia are COVID-19-specific anxiety risk factors. Knowledge of the anxiety risk factors is essential to focus on timely interventions, because anxiety may be a complication of and exacerbate the COVID-19 course.An inverse correlation exists between resilience and anxiety because of COVID-19, and therefore efforts should be made to increase resilience in COVID-19 patients.In COVID-19, important anxiety mechanism is neuroinflammation resulting from activation of the immune system and an ensuing cytokine storm.The general approach to management of anxiety in COVID-19 should be compassionate, similar to that during trauma or disaster, with efforts focussed on instilling a sense of hope and resilience.In selecting pharmacological treatment of anxiety, the stress response and immune system effects should be key. Medications with cardio-respiratory adverse effects should be avoided in patients with respiratory problems.Anxiety is a disorder that will require for long-term follow up at least one month after COVID-19.

ICU Survivors Experience of ICU Diaries: An Ancillary Qualitative Analysis of the ICU Diary Study

Supplemental Digital Content is available in the text.

OBJECTIVES:

To investigate patients’ experience of ICU diaries 6 months after ICU discharge among survivors. This study was designed to add insight into a large randomized study, which found no benefit of the ICU diary to post-traumatic stress disorder among critically ill patients having received mechanical ventilation.

DESIGN:

A preplanned qualitative substudy of patients receiving an ICU diary written by ICU caregivers and families. Six months after ICU discharge, survivors were contacted by a psychologist for a telephone interview using a semi-directive guide.

SETTING:

Thirty-five French ICUs.

PATIENTS:

All ICU survivors having received an ICU diary.

INTERVENTION:

An ICU diary written by both ICU staff and families.

MEASUREMENTS AND MAIN RESULTS:

Among the 332 patients randomized in the intervention group (having had an ICU diary filled by both ICU staff and families), 191 (57.7%) were alive at 6 months and 101 of 191 (52.9%) participated in a telephone interview. They were (median [interquartile range]) 64 years old (53–70 yr old); 65 (64.4%) were men, and 79 (78.2%) were medical patients. Duration of ICU stay was 13 days (8–21 d). Three themes were derived from the thematic analysis: 1) reading the diary: between emotion and pain, 2) how the diary helped, and 3) the bittersweet representation of the diary. For half of the patients, the diary is a good memory of difficult times (55/101, 54.5%), others seem to be more ambivalent about it (28/101, 27.8%), and 37 of 101, 36.6% see it as a painful representation of a time to be forgotten.

CONCLUSIONS:

When reading their ICU diaries, ICU survivors experienced mixed emotions, related to family messages, medical caregiving, and to the severity of their illness. Patients described diaries as a help or a hindrance to recovery, depending on their wish to remember the period or move on from it.

Primary graft dysfunction attenuates improvements in health-related quality of life after lung transplantation, but not disability or depression

Disability, depressive symptoms, and impaired health-related quality of life (HRQL) are common among patients with life-threatening respiratory compromise. We sought to determine if primary graft dysfunction (PGD), a syndrome of acute lung injury, attenuates improvements in patient-reported outcomes after transplantation. In a single-center prospective cohort, we assessed disability, depressive symptoms, and HRQL before and at 3- to 6-month intervals after lung transplantation. We estimated the magnitude of change in disability, depressive symptoms, and HRQL with hierarchical segmented linear mixed-effects models. Among 251 lung transplant recipients, 50 developed PGD Grade 3. Regardless of PGD severity, participants had improvements in disability and depressive symptoms, as well as generic-physical, generic-mental, respiratory-specific, and health-utility HRQL, exceeding 1- to 4-fold the minimally clinically important difference across all instruments. Participants with PGD Grade 3 had a lower magnitude of improvement in generic-physical HRQL and health-utility than in all other participants. Among participants with PGD Grade 3, prolonged mechanical ventilation was associated with greater attenuation of improvements. PGD remains a threat to the 2 primary aims of lung transplantation, extending survival and improving HRQL. Attenuation of improvement persists long after hospital discharge. Future studies should assess if interventions can mitigate the impact of PGD on patient-reported outcomes.

Evaluating the association between unmet healthcare needs and subsequent clinical outcomes: protocol for the Addressing Post-Intensive Care Syndrome-01 (APICS-01) multicentre cohort study

INTRODUCTION

As short-term mortality declines for critically ill patients, a growing number of survivors face long-term physical, cognitive and/or mental health impairments. After hospital discharge, many critical illness survivors require an in-depth plan to address their healthcare needs. Early after hospital discharge, numerous survivors experience inadequate care or a mismatch between their healthcare needs and what is provided. Many patients are readmitted to the hospital, have substantial healthcare resource use and experience long-lasting morbidity. The objective of this study is to investigate the gap in healthcare needs occurring immediately after hospital discharge and its association with hospital readmissions or death for survivors of acute respiratory failure (ARF).

METHODS AND ANALYSIS

In this multicentre prospective cohort study, we will enrol 200 survivors of ARF in the intensive care unit (ICU) who are discharged directly home from their acute care hospital stay. Unmet healthcare needs, the primary exposure of interest, will be evaluated as soon as possible within 1 to 4 weeks after hospital discharge, via a standardised telephone assessment. The primary outcome, death or hospital readmission, will be measured at 3 months after discharge. Secondary outcomes (eg, quality of life, cognitive impairment, depression, anxiety and post-traumatic stress disorder) will be measured as part of 3-month and 6-month telephone-based follow-up assessments. Descriptive statistics will be reported for the exposure and outcome variables along with a propensity score analysis, using inverse probability weighting for the primary exposure, to evaluate the relationship between the primary exposure and outcome.

ETHICS AND DISSEMINATION

The study received ethics approval from Vanderbilt University Medical Center Institutional Review Board (IRB) and the University of Utah IRB (for the Veterans Affairs site). These results will inform both clinical practice and future interventional trials in the field. We plan to disseminate the results in peer-reviewed journals, and via national and international conferences.

TRIAL REGISTRATION DETAILS

ClinicalTrials.gov (NCT03738774). Registered before enrollment of the first patient.

Provider-Documented Anxiety in the ICU: Prevalence, Risk Factors, and Associated Patient Outcomes

PURPOSE

To determine the prevalence of provider-documented anxiety in critically ill patients, associated risk factors, and related patient outcomes.

METHOD

Chart review of 100 randomly sampled, adult patients, with a length of stay ≥48 hours in a medical or trauma/surgical intensive care unit (ICU). Provider-documented anxiety was identified based on a comprehensive retrospective chart review of the ICU stay, searching for any acute episode of anxiety (e.g., documented words related to anxiety, panic, and/or distress).

RESULTS

Of 100 patients, 45% (95% confidence interval: 35%-55%) had documented anxiety, with similar prevalence in medical vs. trauma/surgical ICU. Patients with documented anxiety more frequently had history of anxiety (22% vs. 4%, p = .004) and substance abuse (40% vs. 22%, p = .048). In the ICU, they had greater severity of illness (median (IQR) Acute Physiology Score 16(13,21) vs. 13(8,19), p = .018), screened positive for delirium at least once during ICU stay, (62% vs. 31%, p = .002), benzodiazepines and antipsychotics use (87% vs. 58%, p = .002; 33% vs. 13%, p = .013, respectively), and mental health consultation (31% vs. 18%, p = .132). These patients also had longer ICU and hospital lengths of stay (6(4,11) vs. 4(3,6), p<.001 and 18(10,30) vs. 10(6,16) days, p<.001, respectively) and less frequent discharge back to home (27% vs. 44%, p = .079).

CONCLUSIONS

Documented anxiety, occurring in almost half of ICU patients with length of stay ≥48 hours, was associated with a history of anxiety and/or substance abuse, and greater ICU severity of illness, delirium, psychiatric medications, and length of stay. Increased awareness along with more standardized protocols for assessment of anxiety in the ICU, as well as greater evaluation of non-pharmacological treatments for anxiety symptoms in the ICU are warranted.

Single assessment of delirium severity during postacute intensive care of chronically critically ill patients and its associated factors: post hoc analysis of a prospective cohort study in Germany

OBJECTIVES

To assess the delirium severity (DS), its risk factors and association with adverse patient outcomes in chronically critically ill (CCI) patients.

DESIGN

A prospective cohort study.

SETTING

A tertiary care hospital with postacute intensive care units (ICUs) in Germany.

PARTICIPANTS

N=267 CCI patients with critical illness polyneuropathy and/or critical illness myopathy, aged 18-75 years, who had undergone elective tracheotomy for weaning failure.

INTERVENTIONS

None.

MEASURES

Primary outcomes: DS was assessed using the Confusion Assessment Method for the Intensive Care Unit-7 delirium severity score, within 4 weeks (t1) after the transfer to a tertiary care hospital. In post hoc analyses, univariate linear regressions were employed, examining the relationship of DS with clinical, sociodemographic and psychological variables. Secondary outcomes: additionally, correlations of DS with fatigue (using the Multidimensional Fatigue Inventory-20), quality of life (using the Euro-Quality of Life) and institutionalisation/mortality at 3 (t2) and 6 (t3) months follow-up were computed.

RESULTS

Of the N=267 patients analysed, 9.4% showed severe or most severe delirium symptoms. 4.1% had a full-syndromal delirium. DS was significantly associated with the severity of illness (p=0.016, 95% CI -0.1 to -0.3), number of medical comorbidities (p<0.001, 95% CI .1 to .3) and sepsis (p<0.001, 95% CI .3 to 1.0). Patients with a higher DS at postacute ICU (t1), showed a higher mental fatigue at t2 (p=0.008, 95% CI .13 to .37) and an increased risk for institutionalisation/mortality (p=0.043, 95% CI 1.1 to 28.9/p=0.015, 95% CI 1.5 to 43.2).

CONCLUSIONS

Illness severity is positively associated with DS during postacute care in CCI patients. An adequate management of delirium is essential in order to mitigate functional and cognitive long-term sequelae following ICU.

TRIAL REGISTRATION NUMBER

DRKS00003386.

Approaches to Addressing Post-Intensive Care Syndrome among Intensive Care Unit Survivors. A Narrative Review

Critical illness can be lethal and devastating to survivors. Improvements in acute care have increased the number of intensive care unit (ICU) survivors. These survivors confront a range of new or worsened health states that collectively are commonly denominated post-intensive care syndrome (PICS). These problems include physical, cognitive, psychological, and existential aspects, among others. Burgeoning interest in improving long-term outcomes for ICU survivors has driven an array of potential interventions to improve outcomes associated with PICS. To date, the most promising interventions appear to relate to very early physical rehabilitation. Late interventions within aftercare and recovery clinics have yielded mixed results, although experience in heart failure programs suggests the possibility that very early case management interventions may help improve intermediate-term outcomes, including mortality and hospital readmission. Predictive models have tended to underperform, complicating study design and clinical referral. The complexity of the health states associated with PICS suggests that careful and rigorous evaluation of multidisciplinary, multimodality interventions-tied to the specific conditions of interest-will be required to address these important problems.

COVID-19 and clinical neuropsychology: A review of neuropsychological literature on acute and chronic pulmonary disease

Objective: The illness resulting from Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), better known as COVID-19, has quickly escalated to a worldwide pandemic. Although understanding of the short and long-term manifestations of COVID-19 remains incomplete, there is a preponderance of respiratory pathology in COVID-19 and potential for chronic loss of pulmonary function in recovered patients, raising concerns for associated cognitive impacts.Method: We conducted a narrative review of the existing literature on neuropsychological variables in acute/severe respiratory disease and various forms of chronic pulmonary disease to inform expectations about potential cognitive manifestations of COVID-19.Results: Cognitive dysfunction is common but not inevitable in acute and chronic pulmonary disease, although unique predictors and symptom trajectories appear to be associated with each.Conclusions: Although the full scope of neuropathophysiology associated with COVID-19 remains to be established, pulmonary insults associated with the disease are likely to produce cognitive dysfunction in a substantial percentage of patients.

Participant Retention in Follow-Up Studies of Acute Respiratory Failure Survivors

BACKGROUND

With an increasing number of follow-up studies of acute respiratory failure survivors, there is need for a better understanding of participant retention and its reporting in this field of research. Hence, our objective was to synthesize participant retention data and associated reporting for this field.

METHODS

Two screeners independently searched for acute respiratory failure survivorship studies within a published scoping review to evaluate subject outcomes after hospital discharge in critical illness survivors.

RESULTS

There were 21 acute respiratory failure studies (n = 4,342 survivors) over 47 follow-up time points. Six-month follow-up (range: 2-60 months) was the most frequently reported time point, in 81% of studies. Only 1 study (5%) reported accounting for loss to follow-up in sample-size calculation. Retention rates could not be calculated for 5 (24%) studies. In 16 studies reporting on retention across all time points, retention ranged from 32% to 100%. Pooled retention rates at 3, 6, 12, and 24 months were 85%, 89%, 82%, and 88%, respectively. Retention rates did not significantly differ by publication year, participant mean age, or when comparing earlier (3 months) versus each later follow-up time point (6, 12, or 24 months).

CONCLUSIONS

Participant retention was generally high but varied greatly across individual studies and time points, with 24% of studies reporting inadequate data to calculate retention rate. High participant retention is possible, but resources for optimizing retention may help studies retain participants. Improved reporting guidelines with greater adherence would be beneficial.

Association of self-reported executive function and mood with executive function task performance across adult populations

Executive function (EF) impacts behavior associated with health outcomes. EF can be measured using self-report and/or performance measures, but the correlations between these types of measures are mixed in the extant literature. This study examined self-report and performance-based measures of EF using data from 6 studies, including community and clinical populations (410 participants, ages 19-80, 71% female). Partial correlations revealed significant relationships between performance on the Trail making, Delay Discounting, and Stop Signal tasks with self-reported EF (p < .006 after controlling for age). Mood scores were significantly related to all self-reported domains of EF (p < .0001), and mood and EF scores were correlated over time. When also controlling for mood, correlations between delay discounting and stop signal tasks with self-reported EF remained significant (p < .006). Finally, examining EF scores in participants with and without clinically elevated mood scores showed a wider distribution of self-reported EF scores among those with clinically elevated mood symptoms than among those without. We conclude that self-reported EF is associated with tasks measuring delay discounting and response inhibition in our large, heterogenous population and that assessing EF may be particularly important for those with high levels of mood symptoms.

Complications and Outcomes of Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) is a disease associated with both short- and long-term complications. Acute complications include refractory respiratory failure requiring prolonged dependence on mechanical ventilation and the subsequent need for tracheostomy and gastrostomy tubes, protracted immobilization, and lengthy stays in the intensive care unit resulting in delirium, critical illness myopathy, and polyneuropathy, as well as secondary nosocomial infections. Chronic adverse outcomes of ARDS include irreversible changes such as fibrosis, tracheal stenosis from prolonged tracheostomy tube placement, pulmonary function decline, cognitive impairment and memory loss, posttraumatic stress disorder, depression, anxiety, muscle weakness, ambulatory dysfunction, and an overall poor quality of life. The degree of disability in ARDS survivors is heterogeneous and can be evident even years after hospitalization. Although survival rates have improved over the past 4 decades, mortality remains significant with rates reported as high as 40%. Despite advancements in management, the causes of death in ARDS have remained relatively unchanged since the 1980s with sepsis/septic shock and multiorgan failure at the top of the list.

Review: Post-Intensive Care Syndrome: Unique Challenges in the Neurointensive Care Unit

Within the last couple of decades, advances in critical care medicine have led to increased survival of critically ill patients, as well as the discovery of notable, long-term health challenges in survivors and their loved ones. The terms post-intensive care syndrome (PICS) and PICS-family (PICS-F) have been used in non-neurocritical care populations to characterize the cognitive, psychiatric, and physical sequelae associated with critical care hospitalization in survivors and their informal caregivers (e.g., family and friends who provide unpaid care). In this review, we first summarize the literature on the cognitive, psychiatric, and physical correlates of PICS and PICS-F in non-neurocritical patient populations and draw attention to their long-term negative health consequences. Next, keeping in mind the distinction between disease-related neurocognitive changes and those that are associated directly with the experience of a critical illness, we review the neuropsychological sequelae among patients with common neurocritical illnesses. We acknowledge the clinical factors contributing to the difficulty in studying PICS in the neurocritical care patient population, provide recommendations for future lines of research, and encourage collaboration among critical care physicians in all specialties to facilitate continuity of care and to help elucidate mechanism(s) of PICS and PICS-F in all critical illness survivors. Finally, we discuss the importance of early detection of PICS and PICS-F as an opportunity for multidisciplinary interventions to prevent and treat new neuropsychological deficits in the neurocritical care population.

Challenges in conducting long-term outcomes studies in critical care

PURPOSE OF REVIEW

Evaluating longer term mortality, morbidity, and quality of life in survivors of critical illness is a research priority. This review details the challenges of long-term follow-up studies of critically ill patients and highlights recently proposed methodological solutions.

RECENT FINDINGS

Barriers to long-term follow-up studies of critical care survivors include high rates of study attrition because of death or loss to follow-up, data missingness from experienced morbidity, and lack of standardized outcome as well as reporting of key covariates. A number of recent methods have been proposed to reduce study patients attrition, including minimum data set selection and visits to transitional care or home settings, yet these have significant downsides as well. Conducting long-term follow-up even in the absence of such models carries a high expense, as personnel are very costly, and patients/families require reimbursement for their time and inconvenience.

SUMMARY

There is a reason why many research groups do not conduct long-term outcomes in critical care: it is very difficult. Challenges of long-term follow-up require careful consideration by study investigators to ensure our collective success in data integration and a better understanding of underlying mechanisms of mortality and morbidity seen in critical care survivorship.

Critical Care Recovery Center: a model of agile implementation in intensive care unit (ICU) survivors

BACKGROUND

As many as 70% of intensive care unit (ICU) survivors suffer from long-term physical, cognitive, and psychological impairments known as post-intensive care syndrome (PICS). We describe how the first ICU survivor clinic in the United States, the Critical Care Recovery Center (CCRC), was designed to address PICS using the principles of Agile Implementation (AI).

METHODS

The CCRC was designed using an eight-step process known as the AI Science Playbook. Patients who required mechanical ventilation or were delirious ≥48 hours during their ICU stay were enrolled in the CCRC. One hundred twenty subjects who completed baseline HABC-M CG assessments and had demographics collected were included in the analysis to identify baseline characteristics that correlated with higher HABC-M CG scores. A subset of patients and caregivers also participated in focus group interviews to describe their perceptions of PICS.

RESULTS

Quantitative analyses showed that the cognitive impairment was a major concern of caregivers. Focus group data also confirmed that caregivers of ICU survivors (n = 8) were more likely to perceive cognitive and mental health symptoms than ICU survivors (n = 10). Caregivers also described a need for ongoing psychoeducation about PICS, particularly cognitive and mental health symptoms, and for ongoing support from other caregivers with similar experiences.

CONCLUSIONS

Our study demonstrated how the AI Science Playbook was used to build the first ICU survivor clinic in the United States. Caregivers of ICU survivors continue to struggle with PICS, particularly cognitive impairment, months to years after discharge. Future studies will need to examine whether the CCRC model of care can be adapted to other complex patient populations seen by health-care professionals.

Life after sepsis: an international survey of survivors to understand the post-sepsis syndrome

OBJECTIVE

In this study, we aim to describe the post-sepsis syndrome from the perspective of the sepsis survivors.

DESIGN AND SETTING

The study is a prospective, observational online international survey.

PARTICIPANTS

Sepsis survivors enrolled via social media from 13 September 2014 to 13 September 2016.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Physiologic, physical and psychological function post-sepsis; and patient satisfaction with sepsis-centered care.

RESULTS

1731 completed surveys from 41 countries were analyzed, with 79.9% female respondents, age 47.6 ± 14.4 years. The majority of respondents (47.8%) had sepsis within the last year. Survivors reported an increase in sensory, integumentary, digestive, breathing, chest pain, kidney and musculoskeletal problems after sepsis (all P-value <0.0001). Physical functions such as daily chores, running errands, spelling, reading and reduced libido posed increased difficulty (all P-value <0.0001). Within 7 days prior to completing the survey, the survivors reported varying degrees of anxiety, depression, fatigue and sleep disturbance. Sepsis survivors reported dissatisfaction with a number of hospital support services, with up to 29.3% of respondents stating no social services support was provided for their condition.

CONCLUSIONS

Sepsis survivors suffer from a myriad of physiologic, physical and psychological challenges. Survivors overall reveal dissatisfaction with sepsis-related care, suggesting areas for improvement both in-hospital and post-discharge.

Factors associated with impaired physical functioning and mental health in working-age patients attending a post-intensive care follow-up clinic three months after hospital discharge

Patients recovering from critical illness are often suffering from remarkable limitations in their everyday life. The purpose of this study was to find factors associated with poor physical functioning and mental health after critical illness. The study was conducted among patients who met the inclusion criteria of our post-intensive care unit follow-up clinic. The patients were invited to the follow-up clinic three months after hospital discharge. The participants filled out a RAND-36 questionnaire, underwent a clinical examination and were stratified to those with good or poor recovery according to physical functioning and emotional wellbeing. Altogether 332 out of 351 follow-up clinic attendees had data available for analysis. In physical functioning 40% of patients achieved a poor outcome. In mental health the percentage was 8%. The patients with poor physical functioning had a longer hospital stay and were more likely to have received vasopressors. Eleven out of 16 (69%) multitrauma patients had poor physical functioning. Patients with poor physical functioning had more memories of pain, achieved worse results in a six-minute walk test and were less likely to be able to move independently. The patients with poor mental health had higher delirium incidence and fewer memories of relatives' visits and of nurses. The conclusions of this study were that the memories of pain, multitrauma and longer hospital stay were associated with a poor physical functioning outcome. Delirium and a lack of memories of relatives and nurses were associated with a poor mental health outcome.

Relationship of symptoms associated with ICU-survivorship: An integrative literature review

BACKGROUND

The number of adults who survive a critical illness involving admission to an intensive care unit is increasing. These survivors have an increased risk of developing impairments in cognition, physical function and psychological health.

OBJECTIVE

This integrative literature review examined the literature for studies exploring the relationships among two or more of the variables of interest, i.e. cognitive, physical, and psychological symptoms (depressive, anxiety, or posttraumatic stress) in intensive care unit survivors post-hospital discharge.

METHODS

A literature search was conducted using PubMed, CINHAL and PsycINFO databases.

FINDINGS

While all 13 studies included in the review explored some aspect of a relationship among the variables of interest, none explored associations among all three variables. Five studies explored physical function and psychological symptoms, four studies explored cognitive impairment and psychological symptoms and five studies explored the association among different psychological symptoms. Inconsistencies were found in the study designs, follow-up time frames, patient populations and measures used.

CONCLUSIONS

Further research using well-designed methodologies and standardized instruments is warranted. Gaining a better understanding of the relationships among these impairments has the potential to contribute to the development of screening guidelines, preventative strategies, and treatments.

Long-term psychological outcome after discharge from intensive care

Objective

To investigate the longterm psychological outcome in survivors of critical illness after intensive care unit discharge.

Methods

A prospective cohort of survivors admitted to a mixed intensive care unit between January and September 2010 was evaluated six months and five years after hospital discharge. The Dementia Rating Scale-2, the Hospital Anxiety and Depression Scale, the Posttraumatic stress syndrome 14-questions inventory, the Euro Quality of Life 5 Dimensions (EQ-5-D), and the Visual Analogue Scale (EQ VAS) were assessed at both follow-up periods.

Results

Of 267 patients, 25 patients were evaluated at 6 months after discharge (62 ± 16 years); 12 (48%) presented cognitive impairment, 6 (24%) anxiety, 4 (16%) depression, and 4 (16%) post-traumatic stress disorder. Among those re-evaluated five years after discharge (n = 17; 65 ± 15 years), the frequency of cognitive impairment dropped from 8 (47%) to 3 (18%) (p = 0.063), due to improvement in these patients over time, and other patients did not acquire any dysfunction after discharge. At five years after discharge, only two patients (12%) reported anxiety, and none had depression or post-traumatic stress disorder. No differences were found between the six-month and five-year follow-ups regarding EQ-5-D and EQ VAS.

Conclusion

Survivors do not show a progressive decline in cognitive function or quality of life within five years after intensive care unit discharge. Psychopathological symptoms tend to decrease with time.

Predictors of Major Depressive Disorder following Intensive Care of Chronically Critically Ill Patients

OBJECTIVE

Major depressive disorder (MDD) is a common condition following treatment in the Intensive Care Unit (ICU). Long-term data on MDD in chronically critically ill (CCI) patients are scarce. Hence, the primary aim of the present study was to investigate the frequency and predictors of MDD after intensive care of CCI patients.

MATERIALS AND METHODS

In a prospective cohort study, patients with long-term mechanical ventilation requirements (n=131) were assessed with respect to a diagnosis of MDD, using the Structured Clinical Interview for DSM-IV, three and six months after the transfer from acute ICU to post-acute ICU. Sociodemographic, psychological, and clinical risk factors with p values ≤ 0.1 were identified in a univariate logistic regression analysis and entered in a multivariable logistic regression model. A mediator analysis was run using the bootstrapping method, testing the mediating effect of perceived helplessness during the ICU stay, between the recalled traumatic experience from the ICU and a post-ICU MDD.

RESULTS

17.6% (n=23) of the patients showed a full- or subsyndromal MDD. Perceived helplessness, recalled experiences of a traumatic event from the ICU, symptoms of acute stress disorder, and the diagnosis of posttraumatic stress disorder (PTSD) after ICU could be identified as significant predictors of MDD. In a mediator analysis, perceived helplessness could be proved as a mediator.

CONCLUSIONS

Every fifth CCI patient suffers from MDD up to six months after being discharged from ICU. Particularly, perceived helplessness during the ICU stay seems to mainly affect the long-term evolvement of MDD. CCI patients with symptoms of acute stress disorder/PTSD should also be screened for MDD.

Self-reported fatigue following intensive care of chronically critically ill patients: a prospective cohort study

Background

Protracted treatment on intensive care unit (ICU) sets the patients at increased risk for the development of chronic critical illness (CCI). Muscular and cardio-respiratory deconditioning are common long-term sequelae, going along with a state of chronic fatigue. At present, findings regarding the frequency, long-term course, and associated factors of self-reported fatigue following ICU treatment of CCI patients are lacking.

Methods

CCI patients with the diagnosis of critical illness polyneuropathy/myopathy (CIP/CIM) were assessed at three time points. Four weeks following the discharge from ICU at acute care hospital (t1), eligibility for study participation was asserted. Self-reported fatigue was measured using the Multidimensional Fatigue Inventory (MFI-20) via telephone contact at 3 (t2, n = 113) and 6 months (t3, n = 91) following discharge from ICU at acute care hospital.

Results

At both 3 and 6 months, nearly every second CCI patient showed clinically relevant fatigue symptoms (t2/t3: n = 53/n = 51, point prevalence rates: 46.9%/45.1%). While total fatigue scores remained stable in the whole sample, female patients showed a decrease from 3 to 6 months. The presence of a coronary heart disease, the perceived fear of dying at acute care ICU, a diagnosis of major depression, and the perceived social support were confirmed as significant correlates of fatigue at 3 months. At 6 months, male gender, the number of medical comorbidities, a diagnosis of major depression, and a prior history of anxiety disorder could be identified. A negative impact of fatigue on the perceived health-related quality of life could be ascertained.

Conclusions

Nearly every second CCI patient showed fatigue symptoms up to 6 months post-ICU. Patients at risk should be informed about fatigue, and appropriate treatment options should be offered to them.

Trial registration

The present study was registered retrospectively at the German Clinical Trials Register (date of registration: 13th of December 2011; registration number: DRKS00003386). Date of enrolment of the first participant to the present trial: 09th of November 2011.

Clinician Perspectives on an Electronic Portal to Improve Communication with Patients and Families in the Intensive Care Unit

RATIONALE

Communication in the intensive care unit (ICU) often falls short of patient and family needs, putting them at risk for significant physical and emotional harm. As electronic patient portals rapidly evolve, one designed specifically for the ICU might potentially enhance communication among patients, family members, and clinicians; however, the views of frontline ICU staff on such technology are unknown.

OBJECTIVES

To identify clinician perspectives on the current state of communication among patients, families, and clinicians in the ICU, and assess their views on whether and how an electronic portal may address existing communication deficits and improve care.

METHODS

Three focus groups comprised altogether of 26 clinicians from 6 ICUs, representing several disciplines in an academic medical center in Boston, Massachusetts. Transcripts were analyzed inductively for major themes using grounded theory.

MEASUREMENTS AND MAIN RESULTS

We identified seven themes reflecting clinician perspectives on communication challenges and desired portal functionality: (1) comprehension and literacy; (2) results and updates; (3) patient and family preferences; (4) interclinician communication; (5) family informational needs; (6) the ICU as an unfamiliar environment; and (7) enhancing humanism through technology. Each theme included current gaps in practice, potential benefits and concerns related to an ICU communication portal, and participant recommendations. Benefits included enhanced education, patient/family engagement, and clinician workflow. Challenges included the stress and uncertainty of ICU care, fear of technology replacing human connection, existing interclinician communication failures, and the tension between informing families without overwhelming them.

CONCLUSIONS

Overall, clinicians were cautiously supportive of an electronic portal to enhance communication in the ICU and made several specific recommendations for design and implementation. As new technologies expand opportunities for greater transparency and participation in care, clinician buy-in and positive impact will depend, in large part, on the extent to which the concerns of stakeholders are addressed. At the same time, clinicians anticipate several potential benefits that could help support provider workflow and engage patients and families through enhanced communication and humanism.

Long-Term Quality of Life After Extracorporeal Membrane Oxygenation in ARDS Survivors: Systematic Review and Meta-Analysis

PURPOSE

Extracorporeal membrane oxygenation (ECMO) is an increasingly prevalent treatment for acute respiratory failure (ARF). To evaluate the impact of ECMO support on long-term outcomes for critically ill adults with ARF.

METHODS

We searched electronic databases 1948 through to November 30 2016; selected controlled trials or observational studies of critically ill adults with acute respiratory distress syndrome, examining long-term morbidity specifically health-related quality of life (HRQL); 2 authors independently selected studies, extracted data, and assessed methodological quality.

ANALYSIS

Of the 633 citations, 1 randomized controlled trial and 5 observational studies met the selection criteria. Overall quality of observational studies was moderate to high (mean score on Newcastle-Ottawa scale, 7.2/9; range, 6-8). In 3 studies (n = 245), greater decrements in HRQL were seen for survivors of ECMO when compared to survivors of conventional mechanical ventilation (CMV) as measured by the Short Form 36 (SF-36) scores ([ECMO-CMV]: 5.40 [95% confidence interval, CI, 4.11 to 6.68]). As compared to CMV survivors, those who received ECMO experienced significantly less psychological morbidity (2 studies; n = 217 [ECMO-CMV]: mean weighted difference [MWD], -1.31 [95% CI, -1.98 to -0.64] for depression and MWD, -1.60 [95% CI, -1.80 to -1.39] for anxiety).

CONCLUSIONS

Further studies are required to confirm findings and determine prognostic factors associated with more favorable outcomes in survivors of ECMO.

Return to work and lost earnings after acute respiratory distress syndrome: a 5-year prospective, longitudinal study of long-term survivors

BACKGROUND

Delayed return to work is common after acute respiratory distress syndrome (ARDS), but has undergone little detailed evaluation. We examined factors associated with the timing of return to work after ARDS, along with lost earnings and shifts in healthcare coverage.

METHODS

Five-year, multisite prospective, longitudinal cohort study of 138 2-year ARDS survivors hospitalised between 2004 and 2007. Employment and healthcare coverage were collected via structured interview. Predictors of time to return to work were evaluated using Fine and Grey regression analysis. Lost earnings were estimated using Bureau of Labor Statistics data.

RESULTS

Sixty-seven (49%) of the 138 2-year survivors were employed prior to ARDS. Among 64 5-year survivors, 20 (31%) never returned to work across 5-year follow-up. Predictors of delayed return to work (HR (95% CI)) included baseline Charlson Comorbidity Index (0.77 (0.59 to 0.99) per point; p=0.04), mechanical ventilation duration (0.67 (0.55 to 0.82) per day up to 5 days; p<0.001) and discharge to a healthcare facility (0.49 (0.26 to 0.93); p=0.03). Forty-nine of 64 (77%) 5-year survivors incurred lost earnings, with average (SD) losses ranging from US$38 354 (21,533) to US$43 510 (25,753) per person per year. Jobless, non-retired survivors experienced a 33% decrease in private health insurance and concomitant 37% rise in government-funded coverage.

CONCLUSIONS

Across 5-year follow-up, nearly one-third of previously employed ARDS survivors never returned to work. Delayed return to work was associated with patient-related and intensive care unit/hospital-related factors, substantial lost earnings and a marked rise in government-funded healthcare coverage. These important consequences emphasise the need to design and evaluate vocation-based interventions to assist ARDS survivors return to work.

Preferences of Current and Potential Patients and Family Members Regarding Implementation of Electronic Communication Portals in Intensive Care Units

RATIONALE

The quality of communication with patients and family members in intensive care units (ICUs) is a focus of current interest for clinical care improvement. Electronic communication portals are commonly used in other healthcare settings to improve communication. We do not know whether patients and family members desire such portals in ICUs, and if so, what functionality they should provide.

OBJECTIVES

To define interest in and desired elements of an electronic communication portal among current and potential ICU patients and their family members.

METHODS

We surveyed, via an Internet panel, 1,050 English-speaking adults residing in the United States with a personal or family history of an ICU admission within 10 years (cohort A) and 1,050 individuals without a history of such admission (cohort B). We also administered a survey instrument in person to 105 family members of patients currently admitted to ICUs at an academic medical center in Boston (cohort C).

MEASUREMENTS AND MAIN RESULTS

Respondents, especially current ICU family members, supported an electronic communication portal, including access via an electronic tablet. They wanted at least daily updates, one-paragraph summaries of family meetings including a list of key decisions made, and knowledge of the role and experience of treating clinicians. Overall, they preferred detailed rather than "big picture" information. Respondents were generally comfortable sharing information with their family members. Preferences regarding a communication portal varied significantly by age, sex, ethnicity, and prior experience with ICU hospitalization.

CONCLUSIONS

Electronic communication portals appear welcome in contemporary ICUs. Frequent updates, knowledge about the professional qualifications of clinicians, detailed medical information, and documentation of family meetings are particularly desired.

The relationship between executive dysfunction, depression, and mental health-related quality of life in survivors of critical illness: Results from the BRAIN-ICU investigation

PURPOSE

Although executive dysfunction and depression are common among intensive care unit (ICU) survivors, their relationship has not been evaluated in this population. We sought to determine (1) if executive dysfunction is independently associated with severity of depressive symptoms or worse mental health-related quality of life (HRQOL) in ICU survivors, and (2) if age modifies these associations.

METHODS

In a prospective cohort (n=136), we measured executive dysfunction by the Behavior Rating Inventory of Executive Function-Adult, depression by the Beck Depression Inventory-II, and mental HRQOL by the Short-Form 36. We used multiple linear regression models, adjusting for potential confounders. We included age as an interaction term to test for effect modification.

RESULTS

Executive dysfunction 3 months post-ICU was independently associated with more depressive symptoms and worse mental HRQOL 12 months post-ICU (25th vs 75th percentile of executive functioning scored 4.3 points worse on the depression scale [95% confidence interval, 1.3-7.4; P=.015] and 5 points worse on the Short-Form 36 [95% confidence interval, 1.7-8.3; P=.006]). Age did not modify these associations (depression: P=.12; mental HRQOL: P=.80).

CONCLUSION

Regardless of age, executive dysfunction was independently associated with subsequent worse severity of depressive symptoms and worse mental HRQOL. Executive dysfunction may have a key role in the development of depression.

Psychiatric Symptoms in Acute Respiratory Distress Syndrome Survivors: A 1-Year National Multicenter Study

OBJECTIVE

To evaluate prevalence, severity, and co-occurrence of and risk factors for depression, anxiety, and posttraumatic stress disorder symptoms over the first year after acute respiratory distress syndrome.

DESIGN

Prospective longitudinal cohort study.

SETTINGS

Forty-one Acute Respiratory Distress Syndrome Network hospitals across the United States.

PATIENTS

Six hundred ninety-eight acute respiratory distress syndrome survivors.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Psychiatric symptoms were evaluated by using the Hospital Anxiety and Depression Scale and Impact of Event Scale-Revised at 6 and 12 months. Adjusted prevalence ratios for substantial symptoms (binary outcome) and severity scores were calculated by using Poisson and linear regression, respectively. During 12 months, a total of 416 of 629 patients (66%) with at least one psychiatric outcome measure had substantial symptoms in at least one domain. There was a high and almost identical prevalence of substantial symptoms (36%, 42%, and 24% for depression, anxiety, and posttraumatic stress disorder) at 6 and 12 months. The most common pattern of co-occurrence was having symptoms of all three psychiatric domains simultaneously. Younger age, female sex, unemployment, alcohol misuse, and greater opioid use in the ICU were significantly associated with psychiatric symptoms, whereas greater severity of illness and ICU length of stay were not associated.

CONCLUSIONS

Psychiatric symptoms occurred in two thirds of acute respiratory distress syndrome survivors with frequent co-occurrence. Sociodemographic characteristics and in-ICU opioid administration, rather than traditional measures of critical illness severity, should be considered in identifying the patients at highest risk for psychiatric symptoms during recovery. Given high co-occurrence, acute respiratory distress syndrome survivors should be simultaneously evaluated for a full spectrum of psychiatric sequelae to maximize recovery.

Neuromuscular and neuropsychological assessments in survivors of acute respiratory distress syndrome: exploratory comparisons with an at-risk cohort

BACKGROUND

Long-term studies of survivors of acute respiratory distress syndrome (ARDS) have reported neuromuscular, quality of life, and neuropsychological impairments. This study aims to determine if development of ARDS was associated with neuromuscular weakness and depression at 6-month following hospital discharge in a population-based cohort of patients at high risk for ARDS.

METHODS

A validated lung injury prediction model prospectively identified adult patients at increased risk for ARDS admitted to Mayo Clinic between October 2008 and July 2011. Instruments for functional impairment [Overall Neuropathy Limitations Scale (ONLS)] and the presence of depressive symptoms (the Yale Single Question) were administered at baseline and at 6 months.

RESULTS

Of 107 patients enrolled in the study, 98 (92 %) underwent baseline assessment. Of these, 83 (85 %) were admitted to intensive care, 41 (42 %) developed ARDS, and 67 (68 %) completed assessment at 6 months. Patients with ARDS had longer intensive care and hospital length of stay (7.9 vs. 3.1 days, p = 0.005 and 19.5 vs. 10.6 days, p = 0.004, respectively). There was no difference in reported functional impairment at 6 months from baseline in the ARDS group compared to the non-ARDS group-mean ONLS Total Score 2.95 versus 2.07 p = 0.09 and 3.0 versus 2.1 p = 027, respectively. There was also no difference in the prevalence of depression at 6 months between the ARDS and non-ARDS group (21.9 vs. 30.7 % p = 0.41).

CONCLUSIONS

In this single-center population-based cohort study, survivors of ARDS in the community had similar reported functional impairment and depression prevalence compared to an at-risk cohort that did not develop ARDS.

Recovery and outcomes after the acute respiratory distress syndrome (ARDS) in patients and their family caregivers

Outcomes after acute respiratory distress syndrome (ARDS) are similar to those of other survivors of critical illness and largely affect the nerve, muscle, and central nervous system but also include a constellation of varied physical devastations ranging from contractures and frozen joints to tooth loss and cosmesis. Compromised quality of life is related to a spectrum of impairment of physical, social, emotional, and neurocognitive function and to a much lesser extent discrete pulmonary disability. Intensive care unit-acquired weakness (ICUAW) is ubiquitous and includes contributions from both critical illness polyneuropathy and myopathy, and recovery from these lesions may be incomplete at 5 years after ICU discharge. Cognitive impairment in ARDS survivors ranges from 70 to 100 % at hospital discharge, 46 to 80 % at 1 year, and 20 % at 5 years, and mood disorders including depression and post-traumatic stress disorder (PTSD) are also sustained and prevalent. Robust multidisciplinary and longitudinal interventions that improve these outcomes are still uncertain and data in our literature are conflicting. Studies are needed in family members of ARDS survivors to better understand long-term outcomes of the post-ICU family syndrome and to evaluate how it affects patient recovery.

Symptom burden and health-related quality of life among intensive care unit survivors in Argentina: A prospective cohort study

PURPOSE

Our goal was to describe the evolution of selected physical and psychologic symptoms and identify the determinants of health-related quality of life (HRQOL) after intensive care unit (ICU) discharge.

METHODS

The study is a prospective cohort of consecutive adult patients admitted to a mixed ICU in a university-affiliated hospital, mechanically ventilated for more than 48 hours. During ICU stay, epidemiological data and events probably associated to worsening outcomes were recorded. After discharge, patients were interviewed at 1, 3, 6, and 12 months. Health-related quality of life was assessed with EuroQoL Questionnaire-5 Dimensions, which includes the EQ-index and EQ-Visual Analogue Scale.

RESULTS

One hundred twelve patients were followed up, aged 33 [24-49] years, 68% male, 76% previously healthy, and cranial trauma was the main diagnosis. Physical and psychologic symptoms and moderate/severe problems according to the EQ index progressively decreased after discharge, yet were still highly prevalent after 1 year. EQ index improved from 0.22 [0.01-0.69] to 0.52 [0.08-0.81], 0.66 [0.17-0.79], and 0.68 [0.26-0.86] (P < .001, for all vs month 1). EQ-Visual Analogue Scale remained stable, within acceptable values. Independent determinants of EQ-index were time, duration of mechanical ventilation, shock, weakness, and return to study/work.

CONCLUSIONS

Determinants of HRQOL after ICU discharge were both related to late sequelae of critical illness and to some events occurring in the ICU. Notwithstanding the high symptom burden, patients still perceived their HRQOL as good.

Our paper 20 years later: 1-year survival and 6-month quality of life after intensive care

INTRODUCTION

In the early 1990s, the in-hospital mortality rate of intensive care unit (ICU) patients dropped, and interest in the quality of life (QOL) of ICU survivors increased. In 1996, we published a study to investigate 1-year survival after hospital discharge and 6-month QOL after intensive care. Now, we compare our previous results with those reported in the recent literature to appraise any changes, and new knowledge in the area.

RESULTS

The 1-year survival of ICU patients after hospital discharge is substantial, lower than in the general population, and different among subgroups. Some studies showed a reduction in QOL at 6 months, as in our study, while others showed an improvement. Different results seem to be related mainly to the case mix. Studies on different types of patients found long-term cognitive impairment in ICU survivors, possibly not disease specific. The proportions of patients with neuropsychological morbidities such as posttraumatic stress disorder, anxiety, and depression, described after our study, did not show any change over time.

CONCLUSIONS

Differences between studies on long-term survival and QOL do not allow conclusions to be drawn about change over time. No change was found in neuropsychological morbidities. However, a lack of change may not be viewed negatively, because critically ill patients who survive ICU today may be at higher risk for poor long-term outcome than in the past due to the higher severity of their illness and the more aggressive treatments received. Future studies may provide understanding of the relationships between psychiatric symptoms, cognitive impairment, functional disability, and QOL.

The association between acute respiratory distress syndrome, delirium, and in-hospital mortality in intensive care unit patients

RATIONALE

Both acute respiratory distress syndrome (ARDS) and intensive care unit (ICU) delirium are associated with significant morbidity and mortality. However, the risk of delirium and its impact on mortality in ARDS patients is unknown.

OBJECTIVES

To determine if ARDS is associated with a higher risk for delirium compared with respiratory failure without ARDS, and to determine the association between ARDS and in-hospital mortality after adjusting for delirium.

METHODS

Prospective observational cohort study of adult ICU patients admitted to two urban academic hospitals.

MEASUREMENTS AND MAIN RESULTS

Delirium was assessed daily using the Confusion Assessment Method for the ICU and Richmond Agitation and Sedation Scale. Of the 564 patients in our cohort, 48 had ARDS (9%). Intubated patients with ARDS had the highest prevalence of delirium compared with intubated patients without ARDS and nonintubated patients (73% vs. 52% vs. 21%, respectively; P < 0.001). After adjusting for common risk factors for delirium, ARDS was associated with a higher risk for delirium compared with mechanical ventilation without ARDS (odds ratio [OR], 6.55 [1.56-27.54]; P = 0.01 vs. OR, 1.98 [1.16-3.40]; P < 0.013); reference was nonintubated patients. Although ARDS was significantly associated with hospital mortality (OR, 10.44 [3.16-34.50]), the effect was largely reduced after adjusting for delirium and persistent coma (OR, 5.63 [1.55-20.45]).

CONCLUSIONS

Our findings suggest that ARDS is associated with a greater risk for ICU delirium than mechanical ventilation alone, and that the association between ARDS and in-hospital mortality is weakened after adjusting for delirium and coma. Future studies are needed to determine if prevention and reduction of delirium in ARDS patients can improve outcomes.

Effect of depression on femoral head avascular necrosis from femoral neck fracture in patients younger than 60 years

The purpose of this study was to determine the effect of depression on femoral head avascular necrosis (AVN) from femoral neck fracture in patients younger than 60 years and the relationship between depression and postoperative quality of life. The Beck Depression Inventory-II (BDI-II) was completed by 641 patients (352 men and 289 women; average age, 41.7±10.2 years; range, 20-60 years) postoperatively. Patients were divided into groups according to BDI-II score: a depressed group (BDI-II score of 14 or higher) and a nondepressed group (BDI-II score lower than 14). They were followed for an average of 28 months (range, 24-37 months). The postoperative diagnosis was confirmed by typical radiographs and single photon-emission computed tomography. Quality of life among patients was assessed using the Short Form-36 (SF-36) questionnaire. The overall incidences of depression and AVN were 30.6% (196 of 641) and 20.9% (134 of 641), respectively. Ninety-four (48.0%) patients in the depressed group and 40 (9.0%) patients in the nondepressed group ultimately developed AVN. Symptoms of depression significantly affected AVN. In addition, depression predicted patients' quality of life, as did sex, partner status, employment status, living alone, frequency of exercise, severity of fractures, and length of hospital stay. In a multiple linear regression model analyzing all of these variables, depression was the best independent predictor of quality of life. Depression in patients younger than 60 years with femoral neck fractures may increase postoperative femoral head AVN risk and greatly affect patients' quality of life.