Relationships between mortality, morbidity, and physical function in adults who survived a period of prolonged mechanical ventilation

Analysis of mobility level of COVID-19 patients undergoing mechanical ventilation support: A single center, retrospective cohort study

Background

Severe coronavirus disease 2019 (COVID-19) patients frequently require mechanical ventilation (MV) and undergo prolonged periods of bed rest with restriction of activities during the intensive care unit (ICU) stay. Our aim was to address the degree of mobilization in critically ill patients with COVID-19 undergoing to MV support.

Methods

Retrospective single-center cohort study. We analyzed patients’ mobility level, through the Perme ICU Mobility Score (Perme Score) of COVID-19 patients admitted to the ICU. The Perme Mobility Index (PMI) was calculated [PMI = ΔPerme Score (ICU discharge–ICU admission)/ICU length of stay], and patients were categorized as “improved” (PMI > 0) or “not improved” (PMI ≤ 0). Comparisons were performed with stratification according to the use of MV support.

Results

From February 2020, to February 2021, 1,297 patients with COVID-19 were admitted to the ICU and assessed for eligibility. Out of those, 949 patients were included in the study [524 (55.2%) were classified as “improved” and 425 (44.8%) as “not improved”], and 396 (41.7%) received MV during ICU stay. The overall rate of patients out of bed and able to walk ≥ 30 meters at ICU discharge were, respectively, 526 (63.3%) and 170 (20.5%). After adjusting for confounders, independent predictors of improvement of mobility level were frailty (OR: 0.52; 95% CI: 0.29–0.94; p = 0.03); SAPS III Score (OR: 0.75; 95% CI: 0.57–0.99; p = 0.04); SOFA Score (OR: 0.58; 95% CI: 0.43–0.78; p < 0.001); use of MV after the first hour of ICU admission (OR: 0.41; 95% CI: 0.17–0.99; p = 0.04); tracheostomy (OR: 0.54; 95% CI: 0.30–0.95; p = 0.03); use of extracorporeal membrane oxygenation (OR: 0.21; 95% CI: 0.05–0.8; p = 0.03); neuromuscular blockade (OR: 0.53; 95% CI: 0.3–0.95; p = 0.03); a higher Perme Score at admission (OR: 0.35; 95% CI: 0.28–0.43; p < 0.001); palliative care (OR: 0.05; 95% CI: 0.01–0.16; p < 0.001); and a longer ICU stay (OR: 0.79; 95% CI: 0.61–0.97; p = 0.04) were associated with a lower chance of mobility improvement, while non-invasive ventilation within the first hour of ICU admission and after the first hour of ICU admission (OR: 2.45; 95% CI: 1.59–3.81; p < 0.001) and (OR: 2.25; 95% CI: 1.56–3.26; p < 0.001), respectively; and vasopressor use (OR: 2.39; 95% CI: 1.07–5.5; p = 0.03) were associated with a higher chance of mobility improvement.

Conclusion

The use of MV reduced mobility status in less than half of critically ill COVID-19 patients.

Functional Status After Pulmonary Rehabilitation as a Predictor of Weaning Success and Survival in Patients Requiring Prolonged Mechanical Ventilation

Background: Comprehensive rehabilitation programs are recommended for patients with prolonged mechanical ventilation (PMV) to facilitate functional recovery and ventilator weaning, but whether the functional status after rehabilitation influences outcome has not been clearly evaluated. This study aimed to investigate the association between post-rehabilitation functional status and weaning and survival outcome in PMV patients. Methods: We retrospectively enrolled PMV patients admitted to the respiratory care center (RCC), a post-ICU weaning facility with protocolized rehabilitation program, from January 2016 through December 2017. Functional status was measured by the de Morton Mobility Index (DEMMI), with a cut-off value set at 20 points. The primary outcomes were the weaning status at RCC discharge and hospital survival. The secondary outcomes were overall survival and survival at 3 months after RCC discharge. We followed patients until 3 months after RCC discharge or death. Logistic and Cox regressions were performed to identify significant parameters associated with weaning success and survival. Results: In total, 320 patients were enrolled. The weaning success rate was 71.6%. The survival rate at RCC discharge, hospital discharge, and 3 months after RCC discharge was 89.1, 77.5, and 66.6%, respectively. Post-rehabilitation DEMMI ≥ 20 (odds ratio [OR], 3.514; 95% confidence interval [CI], 1.436-8.598; P = 0.006) was the most significantly associated with weaning success. The weaning success and higher post-rehabilitation DEMMI were the two most significant independent factors associated with both hospital survival (weaning success, OR, 12.272; 95% CI, 5.281-28.517; P < 0.001; post-rehabilitation DEMMI ≥ 20, OR, 6.298; 95% CI, 1.302-30.477; P = 0.022) and survival at 3 months after RCC discharge (weaning success, OR, 38.788; 95% CI, 11.505-130.762; P < 0.001; post-rehabilitation DEMMI ≥ 20, OR, 4.830; 95% CI, 1.072-21.756; P = 0.040). Post-rehabilitation DEMMI ≥ 20 remained significantly association with overall survival at 3 months after RCC discharge (hazard ratio, 0.237; 95% CI, 0.072-0.785; P = 0.018). Conclusions: Post-rehabilitation functional status of PMV patients was independently associated with weaning success, as well as hospital and 3-month overall survival after RCC discharge. Post-rehabilitation, but not pre-rehabilitation, functional status was a significant parameter associated with weaning success and survival in patients requiring PMV.

Resident-Championed Quality Improvement Provides Value: Confronting Prolonged Mechanical Ventilation

BACKGROUND

The Quality In-Training Initiative (QITI) provides hands-on quality improvement education for residents. As our institution has ranked in the bottom quartile for prolonged mechanical ventilation (PMV) according to the National Surgical Quality Improvement Program (NSQIP), we sought to illustrate how our resident-led QITI could be used to determine perioperative contributors to PMV.

MATERIALS AND METHODS

The Model for Improvement framework (developed by Associates in Process Improvement) was used to target postoperative ventilator management. However, baseline findings from our 2016 NSQIP data suggested that preoperative patient factors were more likely contributing to PMV. Subsequently, a retrospective one-to-one case-control study was developed, comparing preoperative NSQIP risk calculator profiles for PMV patients to case-matched patients for age, sex, procedure, and emergent case status. Chart review determined ventilator time, 30-d outcomes, and all-cause mortality.

RESULTS

Forty-five patients with PMV (69% elective) had a median ventilator time of 134 h (interquartile range 87-254). The NSQIP calculator demonstrated increased preoperative risk percentages in PMV patients when compared to case-matched patients for any complication (includes PMV), predicted length of stay, and death (all P < 0.05). Thirty-day outcomes were worse for the PMV group in categories for sepsis, pneumonia, unplanned reoperation, 30-d mortality, rehab facility discharge, and length of stay (all P < 0.05). All-cause mortality was also significantly higher for PMV patients (P < 0.05).

CONCLUSIONS

Resident-led QITI projects enhance resident education while exposing opportunities for improving care. Preoperative patient factors play a larger-than-anticipated role in PMV at our institution. Ongoing efforts are aimed toward preoperative identification and optimization of high-risk patients.

Cambios fisiológicos relacionados con entrenamiento muscular respiratorio en pacientes con ventilación mecánica

Introducción. El entrenamiento muscular respiratorio es una técnica fisioterapéutica usada para incrementar la fuerza de la musculatura respiratoria, sin embargo pocos estudios han abordado los cambios fisiológicos relacionados con esta intervención en pacientes con ventilación mecánica.Objetivo. Determinar los cambios fisiológicos relacionados con el entrenamiento muscular respiratorio en pacientes con ventilación mecánica.Materiales y métodos. Se realizó un análisis de datos secundarios en el marco del estudio “Eficacia del entrenamiento muscular respiratorio en el destete de la ventilación mecánica en pacientes con ventilación mecánica por 48 horas o más: Un ensayo clínico controlado”. La población estuvo conformada por los 62 pacientes del grupo experimental del estudio principal, quienes recibieron entrenamiento muscular respiratorio. Los valores de frecuencia cardiaca, frecuencia respiratoria, presión arterial, saturación de oxígeno y volumen corriente fueron registrados. La diferencia entre el promedio de cada una de las variables fue analizada mediante la prueba de t pareada, mientras que para el análisis de los cambios fisiológicos entre sesiones de entrenamiento se empleó la prueba de Kruskal-Wallis.Resultados. Se observaron diferencias significativas entre las variables fisiológicas antes y después del entrenamiento muscular respiratorio (p<0.05), a excepción del volumen corriente y la presión arterial media (p>0.05). Por el contrario, no se observaron diferencias significativas en ninguna de las variables fisiológicas entre sesiones de entrenamiento (p>0.05)Conclusiones. El entrenamiento muscular respiratorio es una intervención terapéutica viable y tolerable en esta población.

Resource use and outcomes in patients with dialysis-dependent chronic kidney disease admitted to intensive care

BACKGROUND

Central Australia (CA) has a high prevalence of haemodialysis-dependent chronic kidney disease (CKD5D). CKD5D is associated with an increased need for critical care services.

AIMS

To describe the demographic features, critical care resource use and outcomes of patients with CKD5D requiring intensive care admission in CA.

METHODS

Retrospective matched cohort database study. Patients with CKD5D who required admission for critical illness between 1 July 2015 and 30 June 2016 were identified using the Centre for Outcome and Resource Evaluation Outcome Measurement and Evaluation Tool (CORE COMET) and matched with patients without CKD5D. The primary outcome was all cause mortality. Secondary outcomes explored use of critical care and other ongoing healthcare use.

RESULTS

There were 621 critical care admissions during the study period. Of these, CKD5D patients comprised 88 admissions (14%), representing 63 patients. Compared to matched controls, these patients had a similar mortality at a median follow up of 463 days (17% vs 22%, P = 0.50) which did not change when patients with an intensive care unit length of stay (ICU LoS) less than 4 days were excluded. CKD5D patients had a shorter median ICU LoS (1.3 vs 2.9). Although those with CKD5D had higher healthcare resource use, the rate of utilisation remained unchanged by their ICU admission.

CONCLUSIONS

This retrospective observational matched cohort study examining the burden of disease amongst CKD5D patients in CA suggests that there is no additional mortality burden in this group, nor do they require significantly higher critical care resources compared to a matched cohort.

Pre-Frailty Increases the Risk of Adverse Events in Older Patients Undergoing Cardiovascular Surgery

Background

Frailty is identified as a major predictor of adverse outcomes in older surgical patients. However, the outcomes in pre-frail patients after cardiovascular surgery remain unknown.

Objective

To investigate the main outcomes (length of stay, mechanical ventilation time, stroke and in-hospital death) in pre-frail patients in comparison with no-frail patients after cardiovascular surgery.

Methods

221 patients over 65 years old, with established diagnosis of myocardial infarction or valve disease were enrolled. Patients were evaluated by Clinical Frailty Score (CFS) before surgery and allocated into 2 groups: no-frailty (CFS 1~3) vs. pre-frailty (CFS 4) and followed up for main outcomes. For all analysis, the statistical significance was set at 5% (p < 0.05).

Results

No differences were found in anthropometric and demographic data between groups (p > 0.05). Pre-frail patients showed a longer mechanical ventilation time (193 ± 37 vs. 29 ± 7 hours; p<0.05) than no-frail patients; similar results were observed for length of stay at the intensive care unit (5 ± 1 vs. 3 ± 1 days; p < 0.05) and total time of hospitalization (12 ± 5 vs. 9 ± 3 days; p < 0.05). In addition, the pre-frail group had a higher number of adverse events (stroke 8.3% vs. 3.9%; in-hospital death 21.5% vs. 7.8%; p < 0.05) with an increased risk for development stroke (OR: 2.139, 95% CI: 0.622-7.351, p = 0.001; HR: 2.763, 95%CI: 1.206-6.331, p = 0.0001) and in-hospital death (OR: 1.809, 95% CI: 1.286-2.546, p = 0.001; HR: 1.830, 95% CI: 1.476-2.269, p = 0.0001). Moreover, higher number of pre-frail patients required homecare services than no-frail patients (46.5% vs. 0%; p < 0.05).

Conclusion

Patients with pre-frailty showed longer mechanical ventilation time and hospital stay with an increased risk for cardiovascular events compared with no-frail patients.

Mobilization of prolonged mechanical ventilation patients: An integrative review

Mobilization of mechanical ventilation patients has broadened to include patients requiring prolonged mechanical ventilation (PMV). A previous systematic review outlined methodological flaws in the literature. The purpose of this integrative review is to evaluate existing publications to determine if mobilization interventions in PMV patients improve physical function, weaning rates, pulmonary mechanics, and hospital outcomes. An electronicsearch covering 2005-2016, included five bibliographic databases: CINHAL, PubMed, PEDro, EMBASE, and Web of Science. Key terms: PMV, mobilization, therapy, and rehabilitation. Eight research studies were identified; 3 RCT's, 3 medical records reviews, 1 prospective cohort, and 1 undefined prospective interventional. Improvements in functional status, shorter duration of mechanical ventilation and hospitalization, decreased mortality, and superior 1-year survival rates in mobilized PMV patients were reported. Persistent methodological limitations impair the ability to determine if these outcomes were the result of improvements in pulmonary mechanics, overall functional status, or a combination of both.

Implementation of a Progressive Mobilization Program in a Medical-Surgical Intensive Care Unit

BACKGROUND

Current literature supports implementation of progressive mobility protocols in intensive care units. Education can help nurses overcome barriers to mobility and increase knowledge about the positive effects of mobility.

OBJECTIVE

To evaluate the effect of education for a progressive mobilization program for intensive care nurses on knowledge and performance.

METHODS

A pretest-posttest evaluation was conducted for 41 nurses, and a chart review was performed before and after implementation of the educational intervention to evaluate changes in knowledge and mobilization.

RESULTS

Scores after the educational intervention were significantly higher than scores before the intervention (t = 2.02; P < .001). Overall mobilization (P = .04) and dangling (P = .01) increased significantly after the education. No significant increases occurred in ambulating or getting patients up to a chair.

CONCLUSIONS

Mobilization education was effective and increased nurses' knowledge about the benefits of mobility for critically ill patients. The educational program also affected how nurses performed mobility interventions. Although provision of education had positive effects on patients' mobility, leadership and coaching are still important components in implementing change.

Music intervention during daily weaning trials-A 6 day prospective randomized crossover trial

PURPOSE

To examine the effect of patient-selected music intervention during daily weaning trials for patients on prolonged mechanical ventilation.

METHODS

Using a crossover repeated measures design, patients were randomized to music vs no music on the first intervention day. Provision of music was alternated for 6 days, resulting in 3 music and 3 no music days. During weaning trials on music days, data were obtained for 30min prior to music listening and continued for 60min while patients listened to selected music (total 90min). On no music days, data were collected for 90min. Outcome measures were heart rate (HR), respiratory rate (RR), oxygen saturation (SpO₂), blood pressure (BP), dyspnea and anxiety assessed with a visual analog scale (VAS-D, VAS-A) and weaning duration (meanh per day on music and non-music days).

RESULTS

Of 31 patients randomized, 23 completed the 6-day intervention. When comparisons were made between the 3 music and 3 no music days, there were significant decreases in RR and VAS-D and a significant increase in daily weaning duration on music days (p<0.05). A multivariate mixed-effects model analysis that included patients who completed ≥2 days of the intervention (n=28) demonstrated significant decreases in HR, RR, VAS-A, and VAS-D and a significant increase in daily weaning duration on music days (p<0.05).

CONCLUSIONS

Providing patient selected music during daily weaning trials is a simple, low-cost, potentially beneficial intervention for patients on prolonged mechanical ventilation. Further study is indicated to test ability of this intervention to promote weaning success and benefits earlier in the weaning process.

Optimizing physical activity among older adults post trauma: Overcoming system and patient challenges

BACKGROUND

By 2050 it is anticipated that close to half (40%) of all trauma patients will be over the age of 65. Recovery for these individuals is more complicated than among younger individuals. Early mobilization has been shown to improve outcomes. Unfortunately, there are many challenges to early mobilization. The Function Focused Care Intervention was developed to overcome these challenges.

PURPOSE

The purpose of this paper was to describe the initial recruitment of the first 25 participants and delineate the challenges and successes associated with implementation of this intervention.

RESULTS

Overall recruitment rates were consistent with other studies and the intervention was implemented as intended. Most patients were female, white and on average 79 years of age. Optimizing physical activity of patients was a low priority for the nurses with patient safety taking precedence. Patients spent most of the time in bed. Age, depression and tethering were the only factors that were associated with physical activity and functional outcomes of patients.

CONCLUSION

Ongoing work is needed to keep patients physically active in the immediate post trauma recovery period.