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Wang S, Perkins AJ, Chi R, Yates BA, Khan SH, Gao S, Boustani M, Khan BA. Risk factors for dementia in older intensive care unit (ICU) survivors. Alzheimers Dement 2024; 20:278-287. [PMID: 37589315 PMCID: PMC10845165 DOI: 10.1002/alz.13423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/21/2023] [Accepted: 07/13/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION As the number of older intensive care unit (ICU) survivors grows, there is an urgent need to identify modifiable risk factors for post-ICU dementia. METHODS We performed a secondary data analysis of 3144 ICU patients ≥ 50 years of age without a history of dementia or severe mental illness who were screened as part of the Pharmacological Management of Delirium (PMD) study. Delirium was assessed using the Confusion Assessment Method for the ICU. Dementia was identified using International Classification of Diseases Ninth and Tenth revision codes for dementia or prescription of anti-dementia medication. RESULTS Average age (standard deviation) was 65.2 ± 9.5 years; 50.4% were female; and 37.3% were Black. Analyses identified stroke (adjusted hazard ratio [HR] 2.49; 95% confidence interval [CI: 1.52, 4.07], P < 0.001), and depression (adjusted HR 3.03; 95% CI [1.80, 5.10], P < 0.001) as post-ICU risk factors for dementia. DISCUSSION Future studies will need to examine whether interventions targeting post-ICU stroke and depression can lower dementia incidence in ICU survivors. HIGHLIGHTS Risk factors for post-intensive care unit (ICU) dementia were distinct from those of Alzheimer's disease. Cardiovascular risk factors were not associated with dementia in older ICU survivors. Post-ICU stroke was associated with a higher risk of dementia in older ICU survivors. Post-ICU depression was associated with a higher risk of dementia in older ICU survivors.
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Affiliation(s)
- Sophia Wang
- Department of PsychiatryIU Health Neuroscience CenterIndiana University School of MedicineIndianapolisIndianaUSA
- Indiana Alzheimer's Disease Research CenterIndiana University School of MedicineIndianapolisIndianaUSA
| | - Anthony J. Perkins
- Department of Biostatistics and Health Data ScienceIndiana University School of MedicineIndianapolisIndianaUSA
| | - Rosalyn Chi
- Division of PulmonaryCritical Care, Sleep and Occupational Medicine, Department of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Brandon A. Yates
- Indiana Center for Musculoskeletal HealthIndiana University School of MedicineIndianapolisIndianaUSA
- IU Center of Aging ResearchRegenstrief InstituteIndianapolisIndianaUSA
| | - Sikandar H. Khan
- Division of PulmonaryCritical Care, Sleep and Occupational Medicine, Department of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- IU Center of Aging ResearchRegenstrief InstituteIndianapolisIndianaUSA
| | - Sujuan Gao
- Indiana Alzheimer's Disease Research CenterIndiana University School of MedicineIndianapolisIndianaUSA
- Department of Biostatistics and Health Data ScienceIndiana University School of MedicineIndianapolisIndianaUSA
| | - Malaz Boustani
- Division of PulmonaryCritical Care, Sleep and Occupational Medicine, Department of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- IU Center of Aging ResearchRegenstrief InstituteIndianapolisIndianaUSA
- Indiana University Center of Health Innovation and Implementation ScienceIndianapolisIndianaUSA
- Sandra Eskenazi Center for Brain Care InnovationEskenazi HospitalIndianapolisIndianaUSA
- Division of Geriatrics and General Internal MedicineDepartment of Internal MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Babar A. Khan
- Division of PulmonaryCritical Care, Sleep and Occupational Medicine, Department of MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- IU Center of Aging ResearchRegenstrief InstituteIndianapolisIndianaUSA
- Indiana University Center of Health Innovation and Implementation ScienceIndianapolisIndianaUSA
- Sandra Eskenazi Center for Brain Care InnovationEskenazi HospitalIndianapolisIndianaUSA
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Dong Q, Yang Y, Tang Q, Yang M, Lan A, Xiao H, Wei J, Cao X, Xian Y, Yang Q, Chen D, Zhao J, Li S. Effects of early cognitive rehabilitation training on cognitive function and quality of life in critically ill patients with cognitive impairment: A randomised controlled trial. Aust Crit Care 2023; 36:708-715. [PMID: 36470777 DOI: 10.1016/j.aucc.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/22/2022] [Accepted: 10/24/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Patients often develop cognitive dysfunction during admission to the ICU and after being transferred out of the ICU, which leads to physical disorders, sleep disorders, and psychological stress.Cognitive rehabilitation training can significantly improve patients' planning, decision-making ability, and executive function. OBJECTIVE The aim of this study was to explore the role of early cognitive rehabilitation training in improving cognitive impairment in critically ill patients. METHODS This study was a prospective, randomised, controlled clinical trial conducted from January 2017 to June 2021. Critically ill patients with cognitive impairment admitted to the Department of Intensive Care Medicine of The Third Hospital of Mianyang were randomly divided into the control (n = 68) and intervention groups (n = 68). Cognitive rehabilitation training (including digital operating system training, music therapy, aerobic training, and mental health intervention) was applied to the patients in the intervention group for 6 months, while the control group did not receive any cognitive intervention. Before 3 and 6 months after enrolment, the Montreal Cognitive Assessment and the 36-Item Short Form Health Survey Scale were used to evaluate cognitive function and quality of life, respectively, in both groups. RESULTS A total of 136 critical patients were included in the final analysis. There were no significant differences in sex, age, years of education, complications, intensive care unit hospitalisation time, mechanical ventilation time, or the total score of the Montreal Cognitive Assessment scale when transferred out of the intensive care unit in 24 hours between the two groups. Six months later, the results of the follow-up showed that the cognitive function score in the intervention group was significantly higher than that in the control group (26.69 ± 2.49 vs. 23.03 ± 3.79). The analysis of quality of life showed that the scores in all areas in the intervention group improved. There were significant differences in physical functioning (69.02 ± 8.14 vs. 63.38 ± 11.94), role physical (62.02 ± 12.18 vs. 58.09 ± 8.83), general health (46.00 ± 15.21 vs. 40.38 ± 13.77), vitality (61.00 ± 11.01 vs. 54.38 ± 13.80), social functioning (70.00 ± 10.29 vs. 64.41 ± 13.61), role emotional (78.00 ± 8.00 vs. 72.15 ± 12.18), and mental health (71.00 ± 12.33 vs. 55.37 ± 10.76) between the two groups (P < 0.05). CONCLUSION Early cognitive rehabilitation training can improve cognitive impairment in critically ill patients and their quality of life.
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Affiliation(s)
- Qionglan Dong
- Department of Critical Care Medicine, Southwest Medical University, LuZhou, Sichuan Province, 646000, China; Department of Critical Care Medicine, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan Province, 621000, China.
| | - Yuxin Yang
- Department of Critical Care Medicine, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan Province, 621000, China
| | - Qibing Tang
- Department of Critical Care Medicine, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan Province, 621000, China
| | - Mei Yang
- Department of Critical Care Medicine, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan Province, 621000, China
| | - An Lan
- Department of Critical Care Medicine, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan Province, 621000, China
| | - Hongjun Xiao
- Department of Critical Care Medicine, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan Province, 621000, China
| | - Jiaxun Wei
- Department of Critical Care Medicine, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan Province, 621000, China
| | - Xiaofang Cao
- Department of Critical Care Medicine, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan Province, 621000, China
| | - Yao Xian
- Department of Critical Care Medicine, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan Province, 621000, China
| | - Qi Yang
- Department of Rehabilitation Medicine, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan Province, 621000, China
| | - Dongmei Chen
- Department of Rehabilitation Medicine, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan Province, 621000, China
| | - Jun Zhao
- Department of Psychiatry, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan Province, 621000, China
| | - Shiyi Li
- Department of Psychiatry, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, Sichuan Province, 621000, China
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Nomali M, Ayati A, Yadegari M, Nomali M, Modanloo M. Physical Restraint and Associated Factors in Adult Patients in Intensive Care Units: A Cross-sectional Study in North of Iran. Indian J Crit Care Med 2022; 26:192-198. [PMID: 35712746 PMCID: PMC8857706 DOI: 10.5005/jp-journals-10071-24103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background/aim Patients in the intensive care units (ICUs) are at high risk of developing delirium and agitation. Physical restraint (PR) has increased to control these patients which accompanies by adverse consequences. The aim was to determine the PR use and associated factors in patients hospitalized at the ICUs in the North of Iran. Materials and methods In this cross-sectional study, a total of 272 patients in 3 ICUs of 5 Azar referral hospital affiliated to Golestan University of Medical Sciences (Gorgan, Iran) in 2018 were included. Confusion assessment method for the ICU (CAM-ICU), Richmond Agitation-Sedation Scale (RASS), acute physiology and chronic health evaluation II (APACHE II), and Glasgow Coma Scale (GCS) were used to evaluate delirium, sedation level, disease severity, and level of consciousness, respectively. Analysis was done by STATA version 14.2 (StataCorp LP, College Station, Texas), univariate and multiple analyses. Results Data from 272 patients were analyzed (mean age of 45.8 ± 21.3 years). PR was used for 74.5% of patients. Restrained patients had more severe disease [mean of APACHE II score, 20.20 (7.5) vs 11.6 (7.1)], longer length of stay [mean of 10 (5.5) vs 5.5 (4.6) days], and lower level of consciousness [mean of GCS score, 8.7 (3.5) vs 13.5 (3.3)] than patients without it. CAM-ICU was positive in majority of patients (79.5 vs 10.4%) and agitation level of RASS score was higher in restrained patients (31.7 vs 3.0%). Associated factors in multiple analysis were use of sedative and psychoactive drugs [odds ratio (OR), 2.85; 95% confidence interval (CI): 1.04-7.82], presence of delirium (OR, 15.13; 95% CI: 4.61-49.65), deep sedation (OR, 0.04; 95% CI: 0.00-0.45), and GCS score (OR, 0.69; 95% CI: 0.53-0.9). Conclusion This study revealed the high use of PR in the ICUs, and use of sedative and psychoactive drugs, presence of delirium, deep sedation, and GCS score were such associated factors. How to cite this article Nomali M, Ayati A, Yadegari M, Nomali M, Modanloo M. Physical Restraint and Associated Factors in Adult Patients in Intensive Care Units: A Cross-sectional Study in North of Iran. Indian J Crit Care Med 2022;26(2):192-198.
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Affiliation(s)
- Mahin Nomali
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran; Student Research Center, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Aryan Ayati
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Yadegari
- Bandar-e gaz Shohada Hospital, Golestan University of Medical Sciences, Gorgan, Iran
| | - Mahdis Nomali
- Alejalil Hospital, Golestan University of Medical Sciences, Gorgan, Iran
| | - Mahnaz Modanloo
- Nursing Research Center, Faculty of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Iran
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Tugnoli S, Spadaro S, Corte FD, Valpiani G, Volta CA, Caracciolo S. Health Related Quality of Life and Mental Health in ICU Survivors: Post-Intensive Care Syndrome Follow-Up and Correlations between the 36-Item Short Form Health Survey (SF-36) and the General Health Questionnaire (GHQ-28). Health (London) 2022. [DOI: 10.4236/health.2022.145037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Navarra-Ventura G, Gomà G, de Haro C, Jodar M, Sarlabous L, Hernando D, Bailón R, Ochagavía A, Blanch L, López-Aguilar J, Fernández-Gonzalo S. Virtual Reality-Based Early Neurocognitive Stimulation in Critically Ill Patients: A Pilot Randomized Clinical Trial. J Pers Med 2021; 11:jpm11121260. [PMID: 34945732 PMCID: PMC8703623 DOI: 10.3390/jpm11121260] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/09/2021] [Accepted: 11/24/2021] [Indexed: 01/04/2023] Open
Abstract
This study focuses on the application of a non-immersive virtual reality (VR)-based neurocognitive intervention in critically ill patients. Our aim was to assess the feasibility of direct outcome measures to detect the impact of this digital therapy on patients’ cognitive and emotional outcomes. Seventy-two mechanically ventilated adult patients were randomly assigned to the “treatment as usual” (TAU, n = 38) or the “early neurocognitive stimulation” (ENRIC, n = 34) groups. All patients received standard intensive care unit (ICU) care. Patients in the ENRIC group also received adjuvant neurocognitive stimulation during the ICU stay. Outcome measures were a full neuropsychological battery and two mental health questionnaires. A total of 42 patients (21 ENRIC) completed assessment one month after ICU discharge, and 24 (10 ENRIC) one year later. At one-month follow-up, ENRIC patients had better working memory scores (p = 0.009, d = 0.363) and showed up to 50% less non-specific anxiety (11.8% vs. 21.1%) and depression (5.9% vs. 10.5%) than TAU patients. A general linear model of repeated measures reported a main effect of group, but not of time or group–time interaction, on working memory, with ENRIC patients outperforming TAU patients (p = 0.008, ηp2 = 0.282). Our results suggest that non-immersive VR-based neurocognitive stimulation may help improve short-term working memory outcomes in survivors of critical illness. Moreover, this advantage could be maintained in the long term. An efficacy trial in a larger sample of participants is feasible and must be conducted.
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Affiliation(s)
- Guillem Navarra-Ventura
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain; (G.G.); (C.d.H.); (L.S.); (A.O.); (L.B.); (J.L.-A.); (S.F.-G.)
- Department of Mental Health, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-937-23-66-73
| | - Gemma Gomà
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain; (G.G.); (C.d.H.); (L.S.); (A.O.); (L.B.); (J.L.-A.); (S.F.-G.)
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Candelaria de Haro
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain; (G.G.); (C.d.H.); (L.S.); (A.O.); (L.B.); (J.L.-A.); (S.F.-G.)
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Mercè Jodar
- Department of Neurology, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain;
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Leonardo Sarlabous
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain; (G.G.); (C.d.H.); (L.S.); (A.O.); (L.B.); (J.L.-A.); (S.F.-G.)
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - David Hernando
- Instituto Universitario de Investigación en Ingeniería de Aragón, Universidad de Zaragoza, 50018 Zaragoza, Spain; (D.H.); (R.B.)
- Instituto de Investigación Sanitaria Aragón, Universidad de Zaragoza, 50009 Zaragoza, Spain
- Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBERBBN), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Raquel Bailón
- Instituto Universitario de Investigación en Ingeniería de Aragón, Universidad de Zaragoza, 50018 Zaragoza, Spain; (D.H.); (R.B.)
- Instituto de Investigación Sanitaria Aragón, Universidad de Zaragoza, 50009 Zaragoza, Spain
- Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBERBBN), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Ana Ochagavía
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain; (G.G.); (C.d.H.); (L.S.); (A.O.); (L.B.); (J.L.-A.); (S.F.-G.)
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Lluís Blanch
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain; (G.G.); (C.d.H.); (L.S.); (A.O.); (L.B.); (J.L.-A.); (S.F.-G.)
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Josefina López-Aguilar
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain; (G.G.); (C.d.H.); (L.S.); (A.O.); (L.B.); (J.L.-A.); (S.F.-G.)
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Sol Fernández-Gonzalo
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain; (G.G.); (C.d.H.); (L.S.); (A.O.); (L.B.); (J.L.-A.); (S.F.-G.)
- Department of Mental Health, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
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Huang M, Gedansky A, Hassett CE, Price C, Fan TH, Stephens RS, Nyquist P, Uchino K, Cho SM. Pathophysiology of Brain Injury and Neurological Outcome in Acute Respiratory Distress Syndrome: A Scoping Review of Preclinical to Clinical Studies. Neurocrit Care 2021; 35:518-527. [PMID: 34297332 PMCID: PMC8299740 DOI: 10.1007/s12028-021-01309-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/21/2021] [Indexed: 02/05/2023]
Abstract
Acute respiratory distress syndrome (ARDS) has been associated with secondary acute brain injury (ABI). However, there is sparse literature on the mechanism of lung-mediated brain injury and prevalence of ARDS-associated secondary ABI. We aimed to review and elucidate potential mechanisms of ARDS-mediated ABI from preclinical models and assess the prevalence of ABI and neurological outcome in ARDS with clinical studies. We conducted a systematic search of PubMed and five other databases reporting ABI and ARDS through July 6, 2020 and included studies with ABI and neurological outcome occurring after ARDS. We found 38 studies (10 preclinical studies with 143 animals; 28 clinical studies with 1175 patients) encompassing 9 animal studies (n = 143), 1 in vitro study, 12 studies on neurocognitive outcomes (n = 797), 2 clinical observational studies (n = 126), 1 neuroimaging study (n = 15), and 13 clinical case series/reports (n = 15). Six ARDS animal studies demonstrated evidence of neuroinflammation and neuronal damage within the hippocampus. Five animal studies demonstrated altered cerebral blood flow and increased intracranial pressure with the use of lung-protective mechanical ventilation. High frequency of ARDS-associated secondary ABI or poor neurological outcome was observed ranging 82-86% in clinical observational studies. Of the clinically reported ABIs (median age 49 years, 46% men), the most common injury was hemorrhagic stroke (25%), followed by hypoxic ischemic brain injury (22%), diffuse cerebral edema (11%), and ischemic stroke (8%). Cognitive impairment in patients with ARDS (n = 797) was observed in 87% (range 73-100%) at discharge, 36% (range 32-37%) at 6 months, and 30% (range 25-45%) at 1 year. Mechanisms of ARDS-associated secondary ABI include primary hypoxic ischemic injury from hypoxic respiratory failure, secondary injury, such as lung injury induced neuroinflammation, and increased intracranial pressure from ARDS lung-protective mechanical ventilation strategy. In summary, paucity of clinical data exists on the prevalence of ABI in patients with ARDS. Hemorrhagic stroke and hypoxic ischemic brain injury were commonly observed. Persistent cognitive impairment was highly prevalent in patients with ARDS.
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Affiliation(s)
- Merry Huang
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Aron Gedansky
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Catherine E Hassett
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Carrie Price
- Albert S. Cook Library, Towson University, Towson, MD, USA
| | - Tracey H Fan
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - R Scott Stephens
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Paul Nyquist
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA.
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Ji Y, Yang X, Wang J, Cai W, Gao F, Wang H. Factors Influencing the Physical Restraint of Patients in the Neurosurgical Intensive Care Unit. Clin Nurs Res 2021; 31:46-54. [PMID: 34008430 DOI: 10.1177/10547738211016874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to investigate the current status of physical restraint of patients in the neurosurgical intensive care unit (NSICU) and analyze the factors influencing this measure using a cross-sectional study design. A total of 312 patients from four tertiary hospitals in NSICU were investigated in Beijing, China. The rate of physical restraint of patients in the NSICU was 42.9%. In 41.8% of cases, nurses performed physical restraint based on experience, and 45.5% of patients had physical restraint-related nursing records. Binary logistic regression analyses revealed that physical restraint was associated with delirium, mild-to-moderate disturbance of consciousness, history of extubation, surgery, and use of sedatives within 24 hour. Analysis of related factors can provide a reference for nurses and managers to improve physical restraint strategies.
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Affiliation(s)
- Yuanyuan Ji
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xin Yang
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jun Wang
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weixin Cai
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fengli Gao
- Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Hongyan Wang
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Fernández-Gonzalo S, Navarra-Ventura G, Bacardit N, Gomà Fernández G, de Haro C, Subirà C, López-Aguilar J, Magrans R, Sarlabous L, Aquino Esperanza J, Jodar M, Rué M, Ochagavía A, Palao DJ, Fernández R, Blanch L. Cognitive phenotypes 1 month after ICU discharge in mechanically ventilated patients: a prospective observational cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:618. [PMID: 33087171 PMCID: PMC7579874 DOI: 10.1186/s13054-020-03334-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 10/06/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND ICU patients undergoing invasive mechanical ventilation experience cognitive decline associated with their critical illness and its management. The early detection of different cognitive phenotypes might reveal the involvement of diverse pathophysiological mechanisms and help to clarify the role of the precipitating and predisposing factors. Our main objective is to identify cognitive phenotypes in critically ill survivors 1 month after ICU discharge using an unsupervised machine learning method, and to contrast them with the classical approach of cognitive impairment assessment. For descriptive purposes, precipitating and predisposing factors for cognitive impairment were explored. METHODS A total of 156 mechanically ventilated critically ill patients from two medical/surgical ICUs were prospectively studied. Patients with previous cognitive impairment, neurological or psychiatric diagnosis were excluded. Clinical variables were registered during ICU stay, and 100 patients were cognitively assessed 1 month after ICU discharge. The unsupervised machine learning K-means clustering algorithm was applied to detect cognitive phenotypes. Exploratory analyses were used to study precipitating and predisposing factors for cognitive impairment. RESULTS K-means testing identified three clusters (K) of patients with different cognitive phenotypes: K1 (n = 13), severe cognitive impairment in speed of processing (92%) and executive function (85%); K2 (n = 33), moderate-to-severe deficits in learning-memory (55%), memory retrieval (67%), speed of processing (36.4%) and executive function (33.3%); and K3 (n = 46), normal cognitive profile in 89% of patients. Using the classical approach, moderate-to-severe cognitive decline was recorded in 47% of patients, while the K-means method accurately classified 85.9%. The descriptive analysis showed significant differences in days (p = 0.016) and doses (p = 0.039) with opioid treatment in K1 vs. K2 and K3. In K2, there were more women, patients were older and had more comorbidities (p = 0.001) than in K1 or K3. Cognitive reserve was significantly (p = 0.001) higher in K3 than in K1 or K2. CONCLUSION One month after ICU discharge, three groups of patients with different cognitive phenotypes were identified through an unsupervised machine learning method. This novel approach improved the classical classification of cognitive impairment in ICU survivors. In the exploratory analysis, gender, age and the level of cognitive reserve emerged as relevant predisposing factors for cognitive impairment in ICU patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier:NCT02390024; March 17,2015.
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Affiliation(s)
- Sol Fernández-Gonzalo
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain. .,Centro de Investigación Biomédica En Red en Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain. .,Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain.
| | - Guillem Navarra-Ventura
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Neus Bacardit
- Mental Health Department, Fundació Althaia - Xarxa Assistencial I Universitaria, Manresa, Spain
| | - Gemma Gomà Fernández
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain
| | - Candelaria de Haro
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Carles Subirà
- Critical Care Center, Fundació Althai, Universitat Internacional de Catalunya, Manresa, Spain
| | - Josefina López-Aguilar
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Leonardo Sarlabous
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain
| | - Jose Aquino Esperanza
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Department of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Mercè Jodar
- Centro de Investigación Biomédica En Red en Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.,Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain.,Neurology Department, Parc Taulí Hospital Universitari, I3PT, UAB, Sabadell, Spain
| | - Montse Rué
- Departament of Basic Medical Sciences, Universitat de Lleida, Lleida, Spain.,Health Services Research Network in Chronic Diseases (REDISSEC), Barcelona, Spain
| | - Ana Ochagavía
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Diego J Palao
- Centro de Investigación Biomédica En Red en Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.,Mental Health Department, Parc Taulí Hospital Universitari, I3PT, UAB, Sabadel, Spain.,Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Rafael Fernández
- Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Critical Care Center, Fundació Althai, Universitat Internacional de Catalunya, Manresa, Spain
| | - Lluís Blanch
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Department of Medicine, Universitat de Barcelona, Barcelona, Spain
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Riordan P, Stika M, Goldberg J, Drzewiecki M. COVID-19 and clinical neuropsychology: A review of neuropsychological literature on acute and chronic pulmonary disease. Clin Neuropsychol 2020; 34:1480-1497. [PMID: 32883155 DOI: 10.1080/13854046.2020.1810325] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Patrick Riordan
- Mental Health Service, Hines VA Medical Center, Hines, IL, USA.,Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
| | - Monica Stika
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
| | - Joshua Goldberg
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
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Nunna K, Al-Ani A, Nikooie R, Friedman LA, Raman V, Wadood Z, Vasishta S, Colantuoni E, Needham DM, Dinglas VD. Participant Retention in Follow-Up Studies of Acute Respiratory Failure Survivors. Respir Care 2020; 65:1382-1391. [PMID: 32234765 PMCID: PMC7906609 DOI: 10.4187/respcare.07461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Krishidhar Nunna
- Department of Critical Care Medicine, Baylor College of Medicine, Houston, Texas
| | - Awsse Al-Ani
- MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Roozbeh Nikooie
- Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - Lisa Aronson Friedman
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Zerka Wadood
- Division of Pulmonary, Critical Care & Sleep Medicine, University of Florida, Gainesville, Florida
| | - Sumana Vasishta
- Mandya Institute of Medical Sciences, Rajiv Gandhi University of Health Sciences, Karnataka, India
| | - Elizabeth Colantuoni
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, Maryland and with the School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Victor D Dinglas
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, Maryland.
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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11
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Kaseda ET, Levine AJ. Post-traumatic stress disorder: A differential diagnostic consideration for COVID-19 survivors. Clin Neuropsychol 2020; 34:1498-1514. [PMID: 32847484 DOI: 10.1080/13854046.2020.1811894] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective: SARS-CoV-2 infection and its oft-associated illness COVID-19 may lead to neuropsychological deficits, either through direct mechanisms (i.e., neurovirulance) or indirect mechanisms, most notably complications caused by the virus (e.g., stroke) or medical procedures (e.g., intubation). The history of past human coronavirus outbreaks resulting in similar health emergencies suggests there will be a substantial prevalence of post-traumatic stress disorder (PTSD) among COVID-19 survivors. To prepare neuropsychologists for the difficult task of differentiating PTSD-related from neuropathology-related deficits in the oncoming wave of COVID-19 survivors, we integrate research across a spectrum of related areas.Methods: Several areas of literature were reviewed: psychiatric, neurologic, and neuropathological outcomes of SARS and MERS patients; neurological outcomes in COVID-19 survivors; PTSD associated with procedures common to COVID-19 patients; and differentiating neuropsychological deficits due to PTSD from those due to acquired brain injuries in other patient groups.Conclusions: Heightened risk of PTSD occurred in MERS and SARS survivors. While data concerning COVID-19 is lacking, PTSD is known to occur in patient groups who undergo similar hospital courses, including ICU survivors, patients who are intubated and mechanically ventilated, and those that experience delirium. Research with patients who develop PTSD in the context of mild traumatic brain injury further suggests that PTSD may account for some or all of a patient's subjective cognitive complaints and neuropsychological test performance. Recommendations are provided for assessing PTSD in the context of COVID-19.
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Affiliation(s)
- Erin T Kaseda
- Department of Psychology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Andrew J Levine
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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12
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Abstract
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.
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Affiliation(s)
- M. Elizabeth Wilcox
- Department of Medicine (Critical Care Medicine), Division of Respirology, University Health Network, Toronto, Canada
- Interdepartment Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine and Center for Health Services Research, Department of Medicine, and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
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13
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Yuan J, Yang MC, Wu MJ, Gou YS. Sedative depth on neurological outcomes in a juvenile rat model of cardiopulmonary resuscitation. Med Hypotheses 2019; 132:109233. [PMID: 31606702 DOI: 10.1016/j.mehy.2019.109233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 05/11/2019] [Accepted: 05/18/2019] [Indexed: 01/26/2023]
Abstract
The guidelines for cardiopulmonary resuscitation (CPR) in pediatric advanced life support suggest that midazolam is the preferred agent for sedation in patients with mild hypothermia, whereas children with cardiac arrest (CA) are at a crucial stage regarding their immature nervous system. Studies have shown that midazolam may have a detrimental effect on the developmental of the pediatric nervous system. Our previous study found that midazolam induced neuronal damage after CPR in young rats. It is speculated that: midazolam causes the potential injury of neurons by inhibiting mitochondrial autophagy expression and is an important factor for the poor prognosis in children after successful CPR. This project intends to adopt the modified asphyxiant CPR model in juvenile rats. Survival rate, neurological function and histopathological changes were evaluated to determine the protective effects of appropriate sedation depth on cerebral ischemia-reperfusion injury in juvenile rats after CPR. Combined with cell biology and molecular biology related technologies, the mechanism by which the mitochondrial pinkl-parkin signaling pathway induces autophagy to inhibit neuronal apoptosis may be key factor in the protective effects of sedation depth on the brain. The aim of this study is to provide experimental evidence and elucidate the mechanisms of improvement of cerebral ischemia-reperfusion injury by sedation depth in children after successful CPR and to lay a theoretical and experimental basis for clinical treatment.
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Affiliation(s)
- Jing Yuan
- The Third People(')s Hospital of Chengdu, The Affiliated Hospital of Southwest Jiaotong University, China
| | - Meng-Chang Yang
- Department of Anesthesiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu 610072, Sichuan, China
| | - Meng-Jun Wu
- Department of Anesthesiology, Chengdu Women and Children(')s Central Hospital, Chengdu 610041, Sichuan, China.
| | - Yong-Sheng Gou
- Department of Orthopedics, Shuangliu First People's Hospital, Chengdu 610200, Sichuan, China.
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14
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Elliott R, Yarad E, Webb S, Cheung K, Bass F, Hammond N, Elliott D. Cognitive impairment in intensive care unit patients: A pilot mixed-methods feasibility study exploring incidence and experiences for recovering patients. Aust Crit Care 2019; 32:131-138. [DOI: 10.1016/j.aucc.2018.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 01/13/2018] [Accepted: 01/14/2018] [Indexed: 12/20/2022] Open
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15
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Abstract
Delirium has been consistently identified as a risk factor for critical illness brain injury, but ICU patients are exposed to a multitude of risk factors for delirium and it remains unclear which of these risk factors should be targeted to improve long-term cognitive outcomes. Because exposure to sedating medications-which are frequently used to treat unwanted yet common symptoms during critical illness-is a risk factor for delirium that is directly controlled by clinicians, the relationship between sedation, delirium, and long-term cognition is of great interest to clinicians, researchers, and patients. This review describes theoretic relationships between sedation, delirium, and long-term cognition and reviews the evidence supporting these theoretic relationships.
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Affiliation(s)
- Timothy D Girard
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 638 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, USA.
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16
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Lane-Fall MB, Kuza CM, Fakhry S, Kaplan LJ. The Lifetime Effects of Injury: Postintensive Care Syndrome and Posttraumatic Stress Disorder. Anesthesiol Clin 2018; 37:135-150. [PMID: 30711227 DOI: 10.1016/j.anclin.2018.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Postintensive care syndrome (PICS) is a heterogeneous syndrome marked by physical, cognitive, and mental health impairments experienced by critical care survivors. It is a syndrome that bears significant human and health care costs. Additional research is needed to identify risk factors and diagnostic, preventative, and treatment strategies for PICS. Trauma intensive care unit patients are particularly vulnerable to posttraumatic stress disorder, which shares some of the adverse long-term consequences of PICS and also requires additional research into effective preventative and management strategies.
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Affiliation(s)
- Meghan B Lane-Fall
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 309 Blockley Hall, Philadelphia, PA 19104, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk # 210, Philadelphia, PA 19104, USA.
| | - Catherine M Kuza
- Department of Anesthesiology and Critical Care, Keck School of Medicine of the University of Southern California, Los Angeles County Health System, 1450 San Pablo Street, Suite 3600, Los Angeles, CA 90033, USA
| | - Samir Fakhry
- Department of Surgery, Synergy Surgicalists, Inc, Reston Hospital Center, 1850 Town Center Parkway Suite 309, Reston, VA 20190, USA
| | - Lewis J Kaplan
- Surgical Services, Department of Surgery, Division of Trauma, Surgical Critical Care and Emergency Surgery, Hospital of the University of Pennsylvania, Veteran's Administration Medical Center, Corporal Michael J Crescenz VA Medical Center, Perelman School of Medicine, University of Pennsylvania, 3900 Woodland Avenue, Philadelphia, PA 19104, USA
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Boncyk C, Nahrwold DA, Hughes CG. Targeting light versus deep sedation for patients receiving mechanical ventilation. JOURNAL OF EMERGENCY AND CRITICAL CARE MEDICINE (HONG KONG, CHINA) 2018; 2:79. [PMID: 30443646 PMCID: PMC6233900 DOI: 10.21037/jeccm.2018.10.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Christina Boncyk
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Daniel A. Nahrwold
- Department of Anesthesiology, Moffitt Cancer Center, Florida, USA
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Christopher G. Hughes
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, USA
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18
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Calsavara AJ, Nobre V, Barichello T, Teixeira AL. Post-sepsis cognitive impairment and associated risk factors: A systematic review. Aust Crit Care 2018. [DOI: 10.1016/j.aucc.2017.06.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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19
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Age related inverse dose relation of sedatives and analgesics in the intensive care unit. PLoS One 2017; 12:e0185212. [PMID: 28957364 PMCID: PMC5619735 DOI: 10.1371/journal.pone.0185212] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 09/10/2017] [Indexed: 11/29/2022] Open
Abstract
Sedative and analgesic practices in intensive care units (ICUs) are frequently based on anesthesia regimes but do not take account of the important patient related factors. Pharmacologic properties of sedatives and analgesics change when used as continuous infusions in ICU compared to bolus or short-term infusions during anesthesia. In a prospective observational cohort study, we investigated the association between patient related factors and sedatives/analgesics doses in patients on mechanical ventilation (MV) and their association with cessation of sedation/analgesia. We included patients expected to receive MV for at least 24 hours and excluded those with difficulty in assessing the depth of sedation. We collected data for the first 72 hours or until extubation, whichever occurred first. Multivariate analysis of variance, multivariate regression as well as logistic regression were used. The final cohort (N = 576) was predominantly male (64%) with mean (SD) age 61.7 (15.6) years, weight 63.4 (18.2) Kg, Acute Physiology and Chronic Health Evaluation II score 28.2 (8) and 30% hospital mortality. Increasing age was associated with reduced propofol and fentanyl doses requirements, adjusted to the weight (p<0.001). Factors associated with higher propofol and fentanyl doses were vasopressor use (Relative mean difference (RMD) propofol 1.56 (95% confidence interval (CI) 1.28–1.90); fentanyl 1.48 (1.25–1.76) and central venous line placement (CVL, RMD propofol 1.64 (1.15–2.33); fentanyl 1.41 (1.03–1.91). Male gender was also associated with higher propofol dose (RMD 1.27 (1.06–1.49). Sedation cessation was less likely to occur in restrained patients (Odds Ratio, OR 0.48 (CI 0.30–0.78) or those receiving higher sedative/analgesic doses (OR propofol 0.98 (CI 0.97–0.99); fentanyl 0.99 (CI 0.98–0.997), independent of depth of sedation. In conclusion, increasing age is associated with the use of lower doses of sedative/analgesic in ICU, whereas CVL and vasopressor use were associated with higher doses.
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20
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Kratz T, Diefenbacher A. [Acute and long-term cognitive consequences of treatment on intensive care units]. DER NERVENARZT 2016; 87:246-52. [PMID: 26910259 DOI: 10.1007/s00115-016-0078-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Following treatment on the intensive care unit (ICU) patients often suffer from acute and long-term cognitive deficits. This is true for patients of all age groups but especially for elderly patients who have undergone surgery and develop postoperative delirium (POD) or postoperative cognitive decline (POCD). Both are associated with severe limitations in the quality of life and long-term outcome. OBJECTIVE Which acute and long-term cognitive effects develop in ICU survivors and how do they influence the outcome? How can POD and POCD be differentiated? METHOD A selective literature search was carried out. RESULTS Following surgery POCD can develop within days to weeks, may persist for weeks or months and can lead to problems in attentiveness even under conditions of inconspicuous consciousness. Remission is possible but may take up to more than 12 months. The POD is a phenomenon characterized by disturbances of consciousness and problems in attention, beginning acutely hours and days postoperatively, can persist for days to weeks and remission can be expected within a few days. While POD often has an organic cause, such as an infection, the pathogenesis of POCD has not been sufficiently elucidated. DISCUSSION Both POD and particularly POCD can lead to a deterioration of cognition following ICU treatment. As efficient treatment still has to be developed preventive methods, such as preoperative screening for risk factors, thorough planning of operative and anesthetic techniques and compensation of risk factors as well as providing assistance to patients, e. g. by a trained nurse should be implemented in the clinical routine more often than is presently the case.
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Affiliation(s)
- T Kratz
- Abt. für Psychiatrie, Psychotherapie und Psychosomatik, Evangelisches Krankenhaus Königin Elisabeth Herzberg gGmbH, Herzbergstr. 79, 10365, Berlin, Deutschland.
| | - A Diefenbacher
- Abt. für Psychiatrie, Psychotherapie und Psychosomatik, Evangelisches Krankenhaus Königin Elisabeth Herzberg gGmbH, Herzbergstr. 79, 10365, Berlin, Deutschland
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21
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Abstract
A growing body of literature has shown that survivors of critical illness often struggle with cognitive impairment that persists months to years after hospital discharge. We describe the epidemiology of this form of cognitive impairment-which we refer to as critical illness brain injury-and review the history and maturation of the investigation of this previously unrecognized, yet common problem. We then review the characteristics of critical illness brain injury, which can vary in severity and typically affects multiple domains of cognition. Finally, we examine known risk factors for critical illness brain injury and, based on these data, suggest approaches to patient management.
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Affiliation(s)
- Timothy D Girard
- Division of Allergy, Pulmonary, and Critical Care Medicine.,Center for Health Services Research, and.,Geriatric Research, Education and Clinical Center (GRECC) Service at the Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee 37212
| | - Robert S Dittus
- Center for Health Services Research, and.,Division of General Internal Medicine and Public Health in the Department of Medicine and The Institute for Medicine and Public Health at the Vanderbilt University School of Medicine, Nashville, Tennessee 37232; .,Geriatric Research, Education and Clinical Center (GRECC) Service at the Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee 37212
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine.,Center for Health Services Research, and.,Geriatric Research, Education and Clinical Center (GRECC) Service at the Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee 37212
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22
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Aitken LM, Castillo MI, Ullman A, Engström Å, Cunningham K, Rattray J. What is the relationship between elements of ICU treatment and memories after discharge in adult ICU survivors? Aust Crit Care 2016; 29:5-14; quiz 15. [PMID: 26775552 DOI: 10.1016/j.aucc.2015.11.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 11/30/2015] [Accepted: 11/30/2015] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVES Patients admitted to an intensive care unit (ICU) often experience distressing memories during recovery that have been associated with poor psychological and cognitive outcomes. The aim of this literature review was to synthesise the literature reporting on relationships between elements of ICU treatment and memories after discharge in adult ICU survivors. REVIEW METHOD USED Integrative review methods were used to systematically search, select, extract, appraise and summarise current knowledge from the available research and identify gaps in the literature. DATA SOURCES The following electronic databases were systematically searched: PubMed, Ovid EMBASE, EBSCOhost CINAHL, PsycINFO and Cochrane Central Register of Controlled Trials. Additional studies were identified through searches of bibliographies. Original quantitative research articles written in English that were published in peer-review journals were included. REVIEW METHODS Data extracted from studies included authors, study aims, population, sample size and characteristics, methods, ICU treatments, ICU memory definitions, data collection strategies and findings. Study quality assessment was based on elements of the Critical Appraisal Skills Programme using the checklists developed for randomised controlled trials and cohort studies. RESULTS Fourteen articles containing data from 13 studies met the inclusion criteria and were included in the final analysis. The relatively limited evidence about the association between elements of ICU treatment and memories after ICU discharge suggest that deep sedation, corticoids and administration of glucose 50% due to hypoglycaemia contribute to the development of delusional memories and amnesia of ICU stay. CONCLUSIONS The body of literature on the relationship between elements of ICU treatment and memories after ICU discharge is small and at its early stages. Larger studies using rigorous study design are needed in order to evaluate the effects of different elements of ICU treatment on the development of memories of the ICU during recovery.
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Affiliation(s)
- Leanne M Aitken
- School of Nursing & Midwifery & NHMRC Centre of Research Excellence in Nursing (NCREN), Centre for Health Practice Innovation, Menzies Health Institute Queensland, Griffith University, Australia; Intensive Care Unit, Princess Alexandra Hospital, Australia; School of Health Sciences, City University London, UK.
| | - Maria I Castillo
- School of Nursing & Midwifery & NHMRC Centre of Research Excellence in Nursing (NCREN), Centre for Health Practice Innovation, Menzies Health Institute Queensland, Griffith University, Australia; Intensive Care Unit, Princess Alexandra Hospital, Australia
| | - Amanda Ullman
- School of Nursing & Midwifery & NHMRC Centre of Research Excellence in Nursing (NCREN), Centre for Health Practice Innovation, Menzies Health Institute Queensland, Griffith University, Australia
| | - Åsa Engström
- Division of Nursing, Department of Health Science, Luleå University of Technology, Sweden
| | - Kathryn Cunningham
- Population Health Sciences, Medical Research Institute, University of Dundee, UK
| | - Janice Rattray
- School of Nursing and Midwifery, University of Dundee, UK
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Chahraoui K, Laurent A, Bioy A, Quenot JP. Psychological experience of patients 3 months after a stay in the intensive care unit: A descriptive and qualitative study. J Crit Care 2015; 30:599-605. [DOI: 10.1016/j.jcrc.2015.02.016] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 02/24/2015] [Accepted: 02/26/2015] [Indexed: 11/25/2022]
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Karnatovskaia LV, Johnson MM, Benzo RP, Gajic O. The spectrum of psychocognitive morbidity in the critically ill: A review of the literature and call for improvement. J Crit Care 2015; 30:130-7. [DOI: 10.1016/j.jcrc.2014.09.024] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 09/07/2014] [Accepted: 09/29/2014] [Indexed: 10/24/2022]
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McGuire JF, Crawford EA, Park JM, Storch EA, Murphy TK, Larson MJ, Lewin AB. Neuropsychological performance across symptom dimensions in pediatric obsessive compulsive disorder. Depress Anxiety 2014; 31:988-96. [PMID: 24523044 DOI: 10.1002/da.22241] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/07/2013] [Accepted: 01/03/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Few studies have examined neuropsychological functioning among youth with obsessive compulsive disorder (OCD), with inconclusive results. Although methodological differences may contribute to inconsistent findings, clinical factors may also account for differential performance. Symptom dimensions are associated with specific patterns of genetic transmission, comorbidity, and treatment outcome, and may also be uniquely associated with neuropsychological performance. This study examined differences in cognitive sequelae and neurocognitive impairment across symptom dimensions among youth with OCD. METHOD Participants included 93 treatment-seeking youth diagnosed with OCD. A trained clinician administered the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) to parents and children together. Afterward, youth completed a battery of neuropsychological tests that assessed nonverbal memory and fluency, verbal memory, verbal fluency, verbal learning, processing speed, and inhibition/switching. RESULTS Across five symptom dimensions, youth exhibiting Hoarding symptoms (χ(2) = 5.21, P = .02) and Symmetry/Ordering symptoms had a greater occurrence of cognitive sequelae (χ(2) = 4.86, P = .03). Additionally, youth with Symmetry/Ordering symptoms had a greater magnitude of cognitive impairment (Mann-Whitney U = 442.50, Z = -2.49, P < .02), with specific deficits identified on nonverbal fluency (P < .01), processing speed (P < .01), and inhibition and switching (P < .02). CONCLUSIONS Neuropsychological deficits identified in youth with Hoarding and Symmetry/Ordering symptoms may suggest that these symptoms have characteristics specific to neurocognitive impairment. Alternatively, symptoms associated with these dimensions may impede youth's performance during testing. Findings advise neuropsychological testing for youth with symptoms on either of these dimensions when concerns about neuropsychological and/or academic impairment are present.
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Affiliation(s)
- Joseph F McGuire
- Department of Psychology, University of South Florida, Tampa, Florida; Department of Pediatrics, University of South Florida, Saint Petersburg, Florida
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Sanders R, Absalom A, Sleigh J. V. ‘For now we see through a glass, darkly’: the anaesthesia syndrome. Br J Anaesth 2014; 112:790-3. [DOI: 10.1093/bja/aeu009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Neuropsychological functioning in youth with obsessive compulsive disorder: an examination of executive function and memory impairment. Psychiatry Res 2014; 216:108-15. [PMID: 24508366 DOI: 10.1016/j.psychres.2014.01.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 01/07/2014] [Accepted: 01/09/2014] [Indexed: 11/22/2022]
Abstract
Preliminary research suggests neuropsychological deficits in youth with obsessive-compulsive disorder (OCD) similar to those in adults; however, small samples and methodological confounds limit interpretation. We aimed to examine the rates and clinical correlates of cognitive sequelae in youth with OCD, focusing on executive functioning and memory abilities. Youth ages 7-17 years with OCD (N=96) completed a hypothesis-driven neuropsychological battery (including the Rey-Osterreith Complex Figure, California Verbal Learning Test, and subtests of the Delis-Kaplan Executive Function System and Wide Range Assessment of Memory and Learning) that primarily assessed executive functioning, memory and processing speed. Cognitive sequelae were identified in 65% of youth (37% using a more stringent definition of impairment). Magnitude of cognitive sequelae was not associated with OCD severity or age; however, greater neuropsychological impairments were found amongst youth prescribed atypical neuroleptics and those diagnosed with comorbid tic disorders. Comorbidity burden was associated with presence of neuropsychological impairment, but was not specific to any single test. Findings suggest that the presence of cognitive sequelae is prevalent amongst treatment-seeking youth with OCD. Deficits were found in executive functioning and non-verbal memory performance but these impairments were not associated with OCD severity.
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Luk E, Sneyers B, Rose L, Perreault MM, Williamson DR, Mehta S, Cook DJ, Lapinsky SC, Burry L. Predictors of physical restraint use in Canadian intensive care units. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R46. [PMID: 24661688 PMCID: PMC4075126 DOI: 10.1186/cc13789] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 03/07/2014] [Indexed: 12/14/2022]
Abstract
Introduction Physical restraint (PR) use in the intensive care unit (ICU) has been associated with higher rates of self-extubation and prolonged ICU length of stay. Our objectives were to describe patterns and predictors of PR use. Methods We conducted a secondary analysis of a prospective observational study of analgosedation, antipsychotic, neuromuscular blocker, and PR practices in 51 Canadian ICUs. Data were collected prospectively for all mechanically ventilated adults admitted during a two-week period. We tested for patient, treatment, and hospital characteristics that were associated with PR use and number of days of use, using logistic and Poisson regression respectively. Results PR was used on 374 out of 711 (53%) patients, for a mean number of 4.1 (standard deviation (SD) 4.0) days. Treatment characteristics associated with PR were higher daily benzodiazepine dose (odds ratio (OR) 1.05, 95% confidence interval (CI) 1.00 to 1.11), higher daily opioid dose (OR 1.04, 95% CI 1.01 to 1.06), antipsychotic drugs (OR 3.09, 95% CI 1.74 to 5.48), agitation (Sedation-Agitation Scale (SAS) >4) (OR 3.73, 95% CI 1.50 to 9.29), and sedation administration method (continuous and bolus versus bolus only) (OR 3.09, 95% CI 1.74 to 5.48). Hospital characteristics associated with PR indicated patients were less likely to be restrained in ICUs from university-affiliated hospitals (OR 0.32, 95% CI 0.17 to 0.61). Mainly treatment characteristics were associated with more days of PR, including: higher daily benzodiazepine dose (incidence rate ratio (IRR) 1.07, 95% CI 1.01 to 1.13), daily sedation interruption (IRR 3.44, 95% CI 1.48 to 8.10), antipsychotic drugs (IRR 15.67, 95% CI 6.62 to 37.12), SAS <3 (IRR 2.62, 95% CI 1.08 to 6.35), and any adverse event including accidental device removal (IRR 8.27, 95% CI 2.07 to 33.08). Patient characteristics (age, gender, Acute Physiology and Chronic Health Evaluation II score, admission category, prior substance abuse, prior psychotropic medication, pre-existing psychiatric condition or dementia) were not associated with PR use or number of days used. Conclusions PR was used in half of the patients in these 51 ICUs. Treatment characteristics predominantly predicted PR use, as opposed to patient or hospital/ICU characteristics. Use of sedative, analgesic, and antipsychotic drugs, agitation, heavy sedation, and occurrence of an adverse event predicted PR use or number of days used.
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Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.medine.2013.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Celis-Rodríguez E, Birchenall C, de la Cal M, Castorena Arellano G, Hernández A, Ceraso D, Díaz Cortés J, Dueñas Castell C, Jimenez E, Meza J, Muñoz Martínez T, Sosa García J, Pacheco Tovar C, Pálizas F, Pardo Oviedo J, Pinilla DI, Raffán-Sanabria F, Raimondi N, Righy Shinotsuka C, Suárez M, Ugarte S, Rubiano S. Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo. Med Intensiva 2013; 37:519-74. [DOI: 10.1016/j.medin.2013.04.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 04/16/2013] [Indexed: 01/18/2023]
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Wolters AE, Slooter AJC, van der Kooi AW, van Dijk D. Cognitive impairment after intensive care unit admission: a systematic review. Intensive Care Med 2013. [PMID: 23328935 DOI: 10.1007/s00134‐012‐2784‐9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE There is increasing evidence that critical illness and treatment in an intensive care unit (ICU) may result in significant long-term morbidity. The purpose of this systematic review was to summarize the current literature on long-term cognitive impairment in ICU survivors. METHODS PubMed/MEDLINE, CINAHL, Cochrane Library, PsycINFO and Embase were searched from January 1980 until July 2012 for relevant articles evaluating cognitive functioning after ICU admission. Publications with an adult population and a follow-up duration of at least 2 months were eligible for inclusion in the review. Studies in cardiac surgery patients or subjects with brain injury or cardiac arrest prior to ICU admission were excluded. The main outcome measure was cognitive functioning. RESULTS The search strategy identified 1,128 unique studies, of which 19 met the selection criteria and were included. Only one article compared neuropsychological test performance before and after ICU admission. The 19 studies that were selected reported a wide range of cognitive impairment in 4-62 % of the patients after a follow-up of 2-156 months. CONCLUSION The results of most studies of the studies reviewed suggest that critical illness and ICU treatment are associated with long-term cognitive impairment. Due to the complexity of defining cognitive impairment, it is difficult to standardize definitions and to reach consensus on how to categorize neurocognitive dysfunction. Therefore, the magnitude of the problem is uncertain.
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Affiliation(s)
- Annemiek E Wolters
- Department of Intensive Care Medicine, University Medical Center Utrecht, Mail Stop F.06.149, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, Coursin DB, Herr DL, Tung A, Robinson BRH, Fontaine DK, Ramsay MA, Riker RR, Sessler CN, Pun B, Skrobik Y, Jaeschke R. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the Intensive Care Unit: executive summary. Am J Health Syst Pharm 2013; 70:53-8. [PMID: 23261901 DOI: 10.1093/ajhp/70.1.53] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002. METHODS The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over six years in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2) and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend..." is used throughout. A weak recommendation, either for or against an intervention, indicated that the tradeoff between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest..." is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflicts of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding. CONCLUSION These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.
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Affiliation(s)
- Juliana Barr
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
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López-Aguilar J, Fernández-Gonzalo MS, Turon M, Quílez ME, Gómez-Simón V, Jódar MM, Blanch L. [Lung-brain interaction in the mechanically ventilated patient]. Med Intensiva 2012; 37:485-92. [PMID: 23260265 DOI: 10.1016/j.medin.2012.10.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 10/05/2012] [Accepted: 10/11/2012] [Indexed: 01/08/2023]
Abstract
Patients with acute lung injury or acute respiratory distress syndrome (ARDS) admitted to the ICU present neuropsychological alterations, which in most cases extend beyond the acute phase and have an important adverse effect upon quality of life. The aim of this review is to deepen in the analysis of the complex interaction between lung and brain in critically ill patients subjected to mechanical ventilation. This update first describes the neuropsychological alterations occurring both during the acute phase of ICU stay and at discharge, followed by an analysis of lung-brain interactions during mechanical ventilation, and finally explores the etiology and mechanisms leading to the neurological disorders observed in these patients. The management of critical patients requires an integral approach focused on minimizing the deleterious effects over the short, middle or long term.
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Affiliation(s)
- J López-Aguilar
- Fundació Parc Taulí, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, España; Institut Universitari Parc Taulí, Universitat Autònoma de Barcelona, Campus d' Excelència Internacional, Bellaterra, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, España; Servicio de Medicina Intensiva, Hospital de Sabadell, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, España
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López-Aguilar J, Fernández-Gonzalo MS, Turon M, Quílez ME, Gómez-Simón V, Jódar MM, Blanch L. [Lung-brain interaction in the mechanically ventilated patient]. Med Intensiva 2012. [PMID: 23260265 DOI: 10.1016/j.medine.2012.10.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Patients with acute lung injury or acute respiratory distress syndrome (ARDS) admitted to the ICU present neuropsychological alterations, which in most cases extend beyond the acute phase and have an important adverse effect upon quality of life. The aim of this review is to deepen in the analysis of the complex interaction between lung and brain in critically ill patients subjected to mechanical ventilation. This update first describes the neuropsychological alterations occurring both during the acute phase of ICU stay and at discharge, followed by an analysis of lung-brain interactions during mechanical ventilation, and finally explores the etiology and mechanisms leading to the neurological disorders observed in these patients. The management of critical patients requires an integral approach focused on minimizing the deleterious effects over the short, middle or long term.
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Affiliation(s)
- J López-Aguilar
- Fundació Parc Taulí, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, España; Institut Universitari Parc Taulí, Universitat Autònoma de Barcelona, Campus d' Excelència Internacional, Bellaterra, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, España; Servicio de Medicina Intensiva, Hospital de Sabadell, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, España
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Abstract
Critically ill patients are routinely provided analgesia and sedation to prevent pain and anxiety, permit invasive procedures, reduce stress and oxygen consumption, and improve synchrony with mechanical ventilation. Regional preferences, patient history, institutional bias, and individual patient and practitioner variability, however, create a wide discrepancy in the approach to sedation of critically ill patients. Untreated pain and agitation increase the sympathetic stress response, potentially leading to negative acute and long-term consequences. Oversedation, however, occurs commonly and is associated with worse clinical outcomes, including longer time on mechanical ventilation, prolonged stay in the intensive care unit, and increased brain dysfunction (delirium and coma). Modifying sedation delivery by incorporating analgesia and sedation protocols, targeted arousal goals, daily interruption of sedation, linked spontaneous awakening and breathing trials, and early mobilization of patients have all been associated with improvements in patient outcomes and should be incorporated into the clinical management of critically ill patients. To improve outcomes, including time on mechanical ventilation and development of acute brain dysfunction, conventional sedation paradigms should be altered by providing necessary analgesia, incorporating propofol or dexmedetomidine to reach arousal targets, and reducing benzodiazepine exposure.
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Johnson RF, Gustin J. Acute lung injury and acute respiratory distress syndrome requiring tracheal intubation and mechanical ventilation in the intensive care unit: impact on managing uncertainty for patient-centered communication. Am J Hosp Palliat Care 2012; 30:569-75. [PMID: 23015728 DOI: 10.1177/1049909112460566] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
A case of acute lung injury (ALI) progressing to acute respiratory distress syndrome (ARDS) requiring tracheal intubation and mechanical ventilation (ETMV) is presented. The palliative medicine service was asked to address concerns expressed by the patient's spouse reflecting uncertainty regarding outcome expectations. Acknowledging and confronting the uncertainties of a critical illness is an essential component of patient-centered communication. Addressing and managing uncertainty for the case scenario requires consideration of both short- and long-term outcomes including mortality, ventilator independence, and adverse effects on quality of life for survivors. In this paper, ALI/ARDS requiring ETMV in the ICU was used as a focal point for preparing a prognostic assessment incorporating these issues. This assessment was based on a review of recently published literature regarding mortality and ventilator independence of survivors for adult patients receiving ETMV for ALI/ARDS in the ICU. In the studies reviewed, long-term survival reported at 60 days to 1 year was 50-73% with greater than 84% of the survivors in each study breathing independently. Selected articles discussing outcomes other than mortality or recovery of respiratory function, particularly quality of life implications for ALI/ARDS survivors, were also reviewed. A case of of ALI/ARDS requiring ETMV in the ICU is used to illustrate the situation of an incapacitated critically ill patient where the outcome is uncertain. Patient-centered communication should acknowledge and address this uncertainty. Managing uncertainty consists of effectively expressing a carefully formulated prognostic assessment and using sound communication principles to alleviate the distress associated with the uncertain outcome probabilities.
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Affiliation(s)
- Robert F Johnson
- Center for Palliative Care, The Ohio State University Medical Center, Columbus, OH 43210, USA.
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Williams TA, Leslie GD. Challenges and possible solutions for long-term follow-up of patients surviving critical illness. Aust Crit Care 2011; 24:175-85. [PMID: 21514838 DOI: 10.1016/j.aucc.2011.03.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 03/17/2011] [Accepted: 03/23/2011] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Surviving critical illness can be life-changing and present new healthcare challenges for patients after discharge from hospital. Optimisation of recovery, rather than mere survival, is an important goal of intensive care. Observational studies have identified decreased quality of life and increased healthcare needs for survivors but loss to follow-up can be high with possible selection bias. Patients in need of support may therefore not be included in study results or allocated appropriate follow up support. AIM To examine the frequency and reasons patients admitted to general ICUs who survive critical illness are excluded from study participation or lost to follow-up and consider the possible implications and solutions. METHOD The literature review included searches of the MEDLINE, EMBASE, and CINAHL databases. Studies (2006-2010) were included if they described follow-up of survivors from general ICUs. RESULTS Ten studies were reviewed. Of the 3269 eligible patients, 14% died after hospital discharge, 27% declined, and 22% were lost to follow-up. Reasons for loss to follow-up included no response, inability to contact the patient, too ill or admitted to another facility. CONCLUSION The most appropriate method of care follow-up has yet to be established but is likely to involve an eclectic model that tailors service provision to support individual patient needs. Identifying methods to minimise loss to follow-up may enhance interpretation of patients' recovery, lead to improvements in clinical practice and inform healthcare service decisions and policy.
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Affiliation(s)
- Teresa A Williams
- School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, Western Australia, Australia.
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Hughes CG, Pandharipande PP. Review articles: the effects of perioperative and intensive care unit sedation on brain organ dysfunction. Anesth Analg 2011; 112:1212-7. [PMID: 21474659 DOI: 10.1213/ane.0b013e318215366d] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Analgesia and sedation are routinely administered to patients in procedural suites, operating rooms, and intensive care units to permit invasive procedures, prevent pain and anxiety, reduce stress and oxygen consumption, allow mechanical ventilation, and for numerous other patient comfort and safety reasons. Increasing research and evidence, however, has implicated commonly prescribed sedative medications as risk factors for untoward events and worse patient outcomes, including brain organ dysfunction manifested as delirium and coma. The effect of sedatives on outcomes is also influenced by the depth of sedation, making it imperative to reduce total exposure to this class of medications. Juxtaposing the widespread necessity and use of sedation with the cost of acute and long-term cognitive dysfunction to patients and society, physicians must now strive to balance patients' demands and requisite for comfort with their own oath to do no harm. Fortunately, our methods of sedation and choice of medications can likely mitigate this cognitive risk. In this review, we detail the effects of perioperative and intensive care unit sedation on the development of delirium and cognitive impairment and provide an evidence-based approach towards analgesia and sedation paradigms to improve patient outcomes.
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Affiliation(s)
- Christopher G Hughes
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee 37212, USA
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Predictors of performance monitoring abilities following traumatic brain injury: the influence of negative affect and cognitive sequelae. Int J Psychophysiol 2011; 82:61-8. [PMID: 21315777 DOI: 10.1016/j.ijpsycho.2011.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 01/31/2011] [Accepted: 02/01/2011] [Indexed: 11/22/2022]
Abstract
Performance monitoring is a cognitive control process modulated by both cognitive and affective variables. This study examined the relative contributions of negative affect (NA) and cognitive sequelae to performance monitoring dysfunction following severe traumatic brain injury (TBI). We used the error-related negativity (ERN) and post-error positivity (Pe) components of the event-related potential (ERP) to test the hypothesis that NA and cognitive sequelae would predict performance monitoring dysfunction beyond time since injury, and injury severity. Nineteen survivors of severe TBI completed neuropsychological tests, measures of NA, and a computerized Stroop task. Scores on NA and neuropsychological measures were standardized to form magnitude of cognitive sequelae and negative affect composite scores. Separate hierarchical regression analyses with ERN and Pe amplitudes as dependent variables and injury severity, time since injury, magnitude of cognitive sequelae, and NA as independent variables indicated that NA and cognitive sequelae significantly predicted ERN amplitude, with a larger relative contribution of NA than cognitive sequelae. Increased levels of NA were associated with decreased amplitude ERN. Cognitive sequelae, but not NA, predicted Pe amplitude. Injury severity and time since injury were not significant predictors. Results suggest that both NA and cognitive sequelae play critical roles in performance monitoring decrements following TBI and indicate a possible dissociation between the ERN and Pe, with the ERN more related to affective processes and the Pe to cognitive processes.
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Surviving critical illness: acute respiratory distress syndrome as experienced by patients and their caregivers. Crit Care Med 2009; 37:2702-8. [PMID: 19865004 DOI: 10.1097/ccm.0b013e3181b6f64a] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To characterize the effects of critical illness in the daily lives and functioning of acute respiratory distress syndrome survivors. Survivors of acute respiratory distress syndrome, a systemic critical illness, often report poor quality of life based on responses to standardized questionnaires. However, the experiences of acute respiratory distress syndrome survivors have not been reported. DESIGN We conducted semistructured interviews with 23 acute respiratory distress syndrome survivors and 24 caregivers 3 to 9 mos after intensive care unit admission, stopping enrollment after thematic saturation was reached. Transcripts were analyzed, using Colaizzi's qualitative methodology, to identify significant ways in which survivors' critical illness experience impacted their lives. SETTING Medical and surgical intensive care units of an academic medical center and a community hospital. PATIENTS We recruited consecutively 31 acute respiratory distress syndrome survivors and their informal caregivers. Eight patients died before completing interviews. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Participants related five key elements of experience as survivors of acute respiratory distress syndrome: 1) pervasive memories of critical care; 2) day-to-day impact of new disability; 3) critical illness defining the sense of self; 4) relationship strain and change; and 5) ability to cope with disability. Survivors described remarkable disability that persisted for months. Caregivers' interviews revealed substantial strain from caregiving responsibilities as well as frequent symptom minimization by patients. CONCLUSIONS The diverse and unique experiences of acute respiratory distress syndrome survivors reflect the global impact of severe critical illness. We have identified symptom domains important to acute respiratory distress syndrome patients who are not well represented in existing health outcomes measures. These insights may aid the development of targeted interventions to enhance recovery and return of function after acute respiratory distress syndrome.
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Lee CM, Herridge MS, Matte A, Cameron JI. Education and support needs during recovery in acute respiratory distress syndrome survivors. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R153. [PMID: 19775467 PMCID: PMC2784376 DOI: 10.1186/cc8053] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Revised: 09/17/2009] [Accepted: 09/23/2009] [Indexed: 11/24/2022]
Abstract
Introduction There is a limited understanding of the long-term needs of survivors of the acute respiratory distress syndrome (ARDS) as they recover from their episode of critical illness. The Timing it Right (TIR) framework, which emphasizes ARDS survivors' journey from the ICU through to community re-integration, may provide a valuable construct to explore the support needs of ARDS survivors during their recovery. Methods Twenty-five ARDS survivors participated in qualitative interviews examining their needs for educational, emotional and tangible support for each phase of the TIR framework. Transcripts were analyzed using framework methodology. Results ARDS survivors' support needs varied across the illness trajectory. During the ICU stay, survivors were generally too ill to require information. The transfer to the general ward was characterized by anxiety surrounding decreased surveillance and concern for future health and treatment. Information needs focused on the events surrounding the acute illness, while physical and emotional needs revolved around physical therapy and psychological support for depression and anxiety. As patients were preparing for hospital discharge, they expressed a desire for specific information about the recovery and rehabilitation process following an episode of ARDS (e.g., outpatient physiotherapy, long-term sequela of the illness). Once in the community, survivors wanted guidance on home care, secondary prevention, and ARDS support groups. Conclusions Our findings support the need for future educational and support interventions to meet the changing needs of ARDS survivors during their recovery.
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Affiliation(s)
- Christie M Lee
- Division of Respirology, University of Toronto, 1 King's College Circle, 6263 Medical Sciences Building, Toronto, ON M5S 1A8, Canada.
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Neurocognitive and Psychiatric Sequelae Among Survivors of Acute Respiratory Distress Syndrome. ACTA ACUST UNITED AC 2008. [DOI: 10.1097/cpm.0b013e3181856410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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