Epidemiology and treatment of psychiatric conditions that develop after critical illness

A 6-y retrospective cohort study of family satisfaction with critical care and decision-making in an Australian intensive care unit

BACKGROUND

Partnering with patients and families to make decisions about care needs is a safety and quality standard in Australian health services that is often not assessed systematically.

OBJECTIVE

The objective of this study was to retrospectively evaluate satisfaction with care and involvement in decision-making among family members of patients admitted to the intensive care unit (ICU).

METHODS

A retrospective cohort analysis of a satisfaction survey administered to family members of patients admitted to an ICU in an Australian metropolitan tertiary care hospital from 2014 to 2019 was conducted. The Family Satisfaction in the Intensive Care Unit questionnaire (FSICU) questionnaire was used to assess overall satisfaction, satisfaction with care, and satisfaction with decision-making on a scale from "poor" (0) to "excellent" (100).

RESULTS

In total, 1322 family members fully completed the survey. Respondents were typically direct relatives of ICU patients (94.2%) with an average age of 52.6 years. Most patients had an ICU length of stay <7 d (56.8%), with most patients being discharged to the ward (96.8%). The overall mean satisfaction score was high among respondents (90.26%). Similarly, mean satisfaction with care (93.06%) and decision-making (89.71%) scores were high. Satisfaction with decision-making scores remained lower than satisfaction with care scores. Multivariable modeling indicated that those younger than 50 years reported higher satisfaction scores (p = 0.006) and those with prolonged lengths of stay in the ICU were associated with lower overall satisfaction scores (p = 0.039). Despite some criticism of waiting times and noise levels, responses showed sincere gratitude for patients' treatment in the ICU and appreciation for the care, skill, and professionalism of the staff.

CONCLUSION

Very high satisfaction levels were reported by family members during this study. Routine, prospective evaluations of family member satisfaction with ICU experiences are feasible and can be leveraged to provide insight for clinicians and administrators seeking to improve family satisfaction with decision-making and care in ICU settings and meet national standards.

Panic Disorder Comorbidity with Medical Conditions and Treatment Implications

Panic disorder (PD) is unique among the anxiety disorders in that panic symptoms are primarily of a physical nature. Consequently, comorbidity with medical illness is significant. This review examines the association between PD and medical illness. We identify shared pathophysiological and psychological correlates and illustrate how physiological activation in panic sufferers underlies their symptom experience in the context of the fight-or-flight response and beyond a situation-specific response pattern. We then review evidence for bodily symptom perception accuracy in PD. Prevalence of comorbidity for PD and medical illness is presented, with a focus on respiratory and cardiovascular illness, irritable bowel syndrome, and diabetes, followed by an outline for potential pathways of a bidirectional association. We conclude by illustrating commonalities in mediating mechanistic pathways and moderating risk factors across medical illnesses, and we discuss implications for diagnosis and treatment of both types of conditions.

[Depressive, anxiety and posttraumatic stress disorders as long-term sequelae of intensive care treatment]

Modern intensive care medicine has led to increased survival rates even after severe life-threatening medical conditions. In self-critical and multidimensional outcome research, however, it must be considered that beyond survival rates treatment on intensive care units (ICU) can also be associated with high long-term rates of depressive, anxiety and posttraumatic stress disorders. Significant correlations with increased somatic morbidity and mortality, persisting cognitive impairments and significant deficits in health-related quality of life must also be taken into consideration. Empirical analysis of the risk factors reveals that a history of premorbid depression, sociodemographic and socioeconomic variables, age, female sex, personality traits, the underlying pathophysiological condition requiring ICU treatment, mode of sedation and analgesia, life support measures, such as mechanical ventilation, manifold traumatic experiences and memories during the stay in the ICU are all of particular pathogenetic importance. In order to reduce principally modifiable risk factors several strategies are illustrated, including well-reflected intensive care sedation and analgesia, special prophylactic medication regarding the major risk of traumatic memories and posttraumatic stress disorder (PTSD), psychological and psychotherapeutic interventions in states of increased acute stress symptoms and aids for personal memories and reorientation.

Impact of Sedation on Cognitive Function in Mechanically Ventilated Patients

The practice of sedation dosing strategy in mechanically ventilated patient has a profound effect on cognitive function. We conducted a comprehensive review of outcome of sedation on mental health function in critically ill patients on mechanical ventilation in the intensive care unit (ICU). We specifically evaluated current sedative dosing strategy and the development of delirium, post-traumatic stress disorders (PTSDs) and agitation. Based on this review, heavy dosing sedation strategy with benzodiazepines contributes to cognitive dysfunction. However, outcome for mental health dysfunction is mixed in regard to newer sedatives agents such as dexmedetomidine and propofol. Moreover, studies that examine the impact of sedatives for persistence of PTSD/delirium and its long-term cognitive and functional outcomes for post-ICU patients are frequently underpowered. Most studies suffer from low sample sizes and methodological variations. Therefore, larger randomized controlled trials are needed to properly assess the impact of sedation dosing strategy on cognitive function.

Review articles: the effects of perioperative and intensive care unit sedation on brain organ dysfunction

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.

Toward an integrated research agenda for critical illness in aging

Aging brings an increased predisposition to critical illness. Patients older than 65 years of age account for approximately half of all intensive care unit (ICU) admissions in the United States, a proportion that is expected to increase considerably with the aging of the population. Emerging research suggests that elderly survivors of intensive care suffer significant long-term sequelae, including accelerated age-related functional decline. Existing evidence-based interventions are frequently underused and their efficacy untested in older subjects. Improving ICU outcomes in the elderly will require not only better methods for translating sound science into improved ICU practice but also an enhanced understanding of the underlying molecular, physiological, and pathophysiological interactions of critical illness with the aging process itself. Yet, significant barriers to research for critical illness in aging exist. We review the state of knowledge and identify gaps in knowledge, research opportunities, and barriers to research, with the goal of promoting an integrated research agenda for critical illness in aging.

Preexisting comorbid psychiatric conditions and mortality in nonsurgical intensive care patients

PURPOSE

To examine the effects of preexisting comorbid psychiatric conditions on mortality in a large cohort of patients admitted to a nonsurgical intensive care unit.

METHODS

This retrospective cohort study involved 66,672 consecutive eligible nonsurgical patients admitted to intensive care units in 129 Veterans Health Administration hospitals during 2005 and 2006. Preexisting comorbid psychiatric conditions were identified by using diagnoses from outpatient encounters in the prior year for depression, anxiety, psychosis, bipolar disorders, and posttraumatic stress disorder. Generalized estimating equations were used to adjust the risks of in hospital and 30-day mortality for demographics, comorbid medical conditions, markers of severity, and abnormal findings on laboratory tests at admission.

RESULTS

Comorbid psychiatric conditions were identified in 28% (n = 18 698) of patients. Patients with preexisting comorbid psychiatric conditions had lower (P < .001) unadjusted in hospital mortality (7.3% vs 8.7%) and 30-day mortality (10.0% vs 12.8%) than did patients without such conditions. After demographics, comorbid medical conditions, and severity were adjusted for, risk of in-hospital mortality among patients with comorbid psychiatric conditions was somewhat higher (odds ratio, 1.07, 95% confidence interval, 1.01-1.14; P = .02), although differences in 30-day mortality (odds ratio, 1.01, 95% confidence interval, 0.94-1.08; P = .70) were no longer significant.

CONCLUSION

Preexisting comorbid psychiatric conditions are common among intensive care patients, but after comorbid medical conditions and severity were adjusted for, preexisting comorbid psychiatric conditions were not associated with a higher risk of 30-day mortality in a large national cohort of veterans.

Patient-specific, time-varying predictors of post-ICU informal caregiver burden: the caregiver outcomes after ICU discharge project

BACKGROUND

The outcomes of informal caregivers of survivors of critical illness likely depend on patient characteristics, which may change over time. To date, few studies have examined patient-specific predictors of post-ICU informal caregiver burden, and none has tested whether predictors vary after hospital discharge.

METHODS

We designed a prospective, longitudinal observational study, enrolling 48 patient-caregiver dyads from four ICUs in a university hospital. Informal caregiver depression symptoms were measured with the Center for Epidemiologic Studies Depression scale. Lifestyle disruption was measured with the Activity Restriction Scale. Linear regression models were built to test for patient- and caregiver-specific predictors of depression symptoms and lifestyle disruption 2, 6, and 12 months after ICU admission.

RESULTS

Patients had a mean (SD) age of 52.5 (19.7) years, 67% were men, median (interquartile range) Acute Physiology and Chronic Health Evaluation score was 52 (38.5, 65). The caregivers had a mean (SD) age of 52.8 (12.8) years, 91.2% were women, and 48% were spouses. Predictors of caregiver depression symptoms were patient gender (men) at 2 and 12 months and tracheostomy at 12 months. Predictors of lifestyle disruption were patient education (more common among high school graduates) and patient gender (men) at 2 months, and tracheostomy, functional dependency, and patient gender (men) at 12 months.

CONCLUSIONS

The determinants of post-ICU informal caregiver burden likely depend on characteristics of the patient as well as the caregiver and may vary over time. Further research is necessary to better understand the longitudinal determinants of burden in order to develop more effective caregiver interventions.

Are intensive care factors associated with depressive symptoms 6 months after acute lung injury?

OBJECTIVE

To evaluate intensive care-related factors as predictors of depressive symptoms 6 months after acute lung injury (ALI).

DESIGN

Prospective cohort study.

SETTING

Thirteen intensive care units (ICUs) in four hospitals in Baltimore, MD.

PATIENTS

Consecutive ALI survivors (n = 160; 71% from medical ICUs) screened for depressive symptoms at 6 months post-ALI.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We prospectively measured 12 features of critical illness and ICU care and used multivariable regression to evaluate associations with depressive symptoms as measured by the Hospital Anxiety and Depression Score. The prevalence of a positive screening for depression (score > or = 8) at 6 months post-ALI was 26%. Depressive symptoms were significantly associated with surgical (vs. medical or trauma) ICU admission (relative risk [RR] 2.2, 95% confidence interval [CI] 1.1-4.2), maximum daily Sequential Organ Failure Assessment Score of >10 (RR 2.1, 95% CI 1.1-3.5), and mean daily ICU benzodiazepine dose of > or = 75 mg of midazolam equivalent (RR 2.1, 95% CI 1.1-3.5).

CONCLUSIONS

Depressive symptoms at 6 months post-ALI are common and potentially associated with ICU-related factors. Mechanisms by which critical illness and intensive care management associate with depressive symptoms merit further investigation.

Depression in general intensive care unit survivors: a systematic review

PURPOSE

To critically review data on the prevalence of depressive symptoms in general intensive care unit (ICU) survivors, risk factors for these symptoms, and their impact on health-related quality of life (HRQOL).

METHODS

We conducted a systematic review using Medline, EMBASE, Cochrane Library, CINAHL, PsycINFO, and a hand-search of 13 journals.

RESULTS

Fourteen studies were eligible. The median point prevalence of "clinically significant" depressive symptoms was 28% (total n = 1,213). Neither sex nor age were consistent risk factors for post-ICU depression, and severity of illness at ICU admission was consistently not a risk factor. Early post-ICU depressive symptoms were a strong risk factor for subsequent depressive symptoms. Post-ICU depressive symptoms were associated with substantially lower HRQOL.

CONCLUSIONS

Depressive symptoms are common in general ICU survivors and negatively impact HRQOL. Future studies should address how factors related to individual patients, critical illness and post-ICU recovery are associated with depression in ICU survivors.

Self-reported symptoms of depression and memory dysfunction in survivors of ARDS

BACKGROUND

Survivors of ARDS have well documented physical limitations, but psychological effects are less clear. We determined the prevalence of self-reported depression and memory dysfunction in ARDS survivors.

METHODS

Six to 48 (median 22) months after ICU discharge, we administered instruments assessing depression symptoms (Beck Depression Inventory-II [BDI-II]) and memory dysfunction (Memory Assessment Clinics Self-Rating Scale [MAC-S]) to 82 ARDS patients who were enrolled in a prospective cohort study in four university-affiliated ICUs.

RESULTS

Sixty-one (74%), 64 (78%), and 61 (74%) patients fully completed the BDI-II, MAC-S (Ability subscale), and MAC-S (Frequency of Occurrence subscale) instruments. Responders (similar to nonresponders) were young (median 42 years, interquartile range [IQR] 35 to 56), with high admission illness severity and organ dysfunction. The median BDI-II score was 12 (IQR 5 to 25). Twenty-five (41%) patients reported moderate-severe depression symptoms and were less likely to return to work than those with minimal-mild symptoms (8/25 [32%] vs 25/36 [69%]; p = 0.005). Median MAC-S (Ability) and MAC-S (Frequency of Occurrence) scores were 76 (IQR 61 to 93) and 91 (IQR 77 to 102), respectively; 8%, 16%, and 20% scored > 2, > 1.5, and > 1 SD(s), respectively, below age-adjusted population norms for each subscale. BDI-II and MAC-S scores were negatively correlated (Spearman coefficient -0.58 and -0.50 for Ability and Frequency of Occurrence subscales, respectively; p < 0.0001). Univariable analyses showed no demographic or illness-severity predictors of BDI-II (including the Cognitive subscale) or MAC-S (both subscales); results were similar when restricted to patients whose primary language was English.

CONCLUSIONS

ARDS survivors report a high prevalence of depression symptoms and a lower prevalence of memory dysfunction 6 to 48 months after ICU discharge. Depression symptoms may hinder the return to work, or patients may report these symptoms because of inability to re-enter the workforce.

Posttraumatic stress disorder in survivors of acute respiratory distress syndrome (ARDS) and septic shock

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) define medical conditions of acute respiratory insufficiency deriving from direct and indirect damage of the alveolar parenchyma and often associated with multiorgan dysfunction (MODS). As a rule, intensive care is based on mechanical ventilation often requiring high doses of sedatives and narcotics. Despite major progress in intensive care medicine the rate of mortality is still very high. Whereas in the past the level of medical progress has been rated based on the mortality rate alone, the many negative somatic and psychological sequelae in long-term-survivors of ARDS are only now being appreciated. From a perspective of C/L psychiatry persisting cognitive dysfunctions, anxiety and mood disorders, posttraumatic stress disorders (PTSD) in their negative impact on health-related quality of life are intensively investigated. In the etiopathogenesis of PTSD associated with ALI/ARDS, many influences have to be discussed, e.g., increases in CO₂ triggering panic affects, a mismatch of norepinephric overstimulation and cortisol insufficiency, negative effects of high doses of benzodiazepines resulting in oversedation, prolonged phases of weaning and more frequent states of delirium. Consolidation and retrieval of traumatic memories of the ICU stay are influenced by complex factors. From a clinical point of view prophylactic stress doses of hydrocortisone may reduce the major risk of PTSD associated with ALI / ARDS.

Intensive care unit hypoglycemia predicts depression during early recovery from acute lung injury

OBJECTIVE

To evaluate the association between intensive care unit blood glucose levels and depression after acute lung injury.

DESIGN

Prospective cohort study.

SETTING

Twelve intensive care units in four hospitals in Baltimore, MD.

PATIENTS

Consecutive acute lung injury survivors (n = 104) monitored during 1717 intensive care unit patient-days and screened for depression at 3 months after acute lung injury.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The prevalence of a positive screening test for depression (Hospital Anxiety and Depression subscale score > or = 8) at follow-up was 28%. After adjustment for confounders, patients with a mean daily minimum intensive care unit glucose level < 100 mg/dL had significant increases in mean depression score (2.1 points, 95% confidence interval 0.6-3.7) and in the likelihood of a positive depression screening test (relative risk 2.6, 95% confidence interval 1.2-4.2). Patients with documented hypoglycemia < 60 mg/dL during their intensive care unit stay also had greater symptoms of depression (2.0 points, 95% confidence interval 0.5-3.5; relative risk 3.6, 95% confidence interval 1.8-5.1). Other factors independently associated with a positive depression screening test included body mass index > 40 kg/m2 (relative risk 3.3, 95% confidence interval 1.2-4.2), baseline depression/anxiety (relative risk 3.9, 95% confidence interval 1.5-6.5), and mean daily intensive care unit benzodiazepine dose > 100 mg of midazolam-equivalent agent (relative risk 2.4, 95% confidence interval 1.1-3.8).

CONCLUSIONS

Hypoglycemia in the intensive care unit is associated with an increased risk of positive screening for depression during early recovery from acute lung injury. Baseline depressive symptoms, morbid obesity, and intensive care unit benzodiazepine dose were also associated with postacute lung injury depressive symptoms. These findings warrant increased glucose monitoring for intensive care unit patients at risk for hypoglycemia and further research on how patient and intensive care unit management factors may contribute to postintensive care unit depression.

Depressive und Angststörungen bei somatischen Krankheiten

Depressiv-ängstliche Störungen sind bei den unterschiedlichen somatischen Erkrankungen häufig. Sie sind nicht nur als Reaktion auf die Situation der Erkrankung zu verstehen, sondern in ein komplexes Bedingungsgefüge eingebettet. Sie sind besonders häufig bei Erkrankungen, die das Zentralnervensystem oder endokrine Regulationssysteme direkt betreffen. Es besteht ein enger Zusammenhang zur Chronizität, Schwere und Prognose der Erkrankung. Eigenständige Effekte von diversen pharmakologischen Substanzgruppen sind wahrscheinlich.

Psychiatric considerations in pulmonary disease

Lung disease is a prominent cause of morbidity and mortality worldwide. When a patient has a common lung disease, such as asthma, or a less prevalent one, such as idiopathic pulmonary fibrosis, psychiatric issues should be considered as an integral part of the care plan for each patient. There have been many studies of psychologic factors and psychiatric syndromes in various lung diseases and their treatment. In this article, the authors focus on an evidence-based approach to reviewing this clinical literature.

Post-traumatic stress disorder and post-traumatic stress symptoms following critical illness in medical intensive care unit patients: assessing the magnitude of the problem

Introduction

Post-traumatic stress disorder (PTSD) is a potentially serious psychiatric disorder that has traditionally been associated with traumatic stressors such as participation in combat, violent assault, and survival of natural disasters. Recently, investigators have reported that the experience of critical illness can also lead to PTSD, although details of the association between critical illness and PTSD remain unclear.

Methods

We conducted keyword searches of MEDLINE and Psych Info and investigations of secondary references for all articles pertaining to PTSD in medical intensive care unit (ICU) survivors.

Results

From 78 screened papers, 16 studies (representing 15 cohorts) and approximately 920 medical ICU patients met inclusion criteria. A total of 10 investigations used brief PTSD screening tools exclusively as opposed to more comprehensive diagnostic methods. Reported PTSD prevalence rates varied from 5% to 63%, with the three highest prevalence estimates occurring in studies with fewer than 30 patients. Loss to follow-up rates ranged from 10% to 70%, with average loss to follow-up rates exceeding 30%.

Conclusion

Exact PTSD prevalence rates cannot be determined due to methodological limitations such as selection bias, loss to follow-up, and the wide use of screening (as opposed to diagnostic) instruments. In general, the high prevalence rates reported in the literature are likely to be overestimates due to the limitations of the investigations conducted to date. Although PTSD may be a serious problem in some survivors of critical illness, data on the whole population are inconclusive. Because the magnitude of the problem posed by PTSD in survivors of critical illness is unknown, there remains a pressing need for larger and more methodologically rigorous investigations of PTSD in ICU survivors.

Long-term cognitive, emotional, and functional outcomes in trauma intensive care unit survivors without intracranial hemorrhage

BACKGROUND

Trauma patients without intracranial hemorrhage or focal neurologic deficits are typically considered low risk for lasting neuropsychological and emotional deficits, and such sequela may be overlooked, especially in those with skull fractures and concussions. We undertook this study to determine the prevalence of and risk factors for persistent cognitive impairment and emotional and functional difficulties in a sample of adult trauma intensive care unit survivors without intracranial hemorrhage.

METHODS

We queried the Vanderbilt University Trauma Registry for all patients admitted during 2003 with an Injury Severity Score >25 and a head computed tomography scan showing no intracranial hemorrhage. Of the 97 patients identified, 58 were evaluated, in person between 12 to 24 months after hospital discharge, with a comprehensive battery of cognitive, emotional, and functional instruments. The Informant Questionnaire of Cognitive Decline in the Elderly-Short Form (IQCODE-SF) was used to evaluate for pre-existing cognitive deficits in patients suspected of having cognitive impairment before their trauma.

RESULTS

A total of 33 (57%) patients were determined to have cognitive impairment, which was most pronounced in the domains of attention and executive functioning/verbal fluency. Of these patients, one (3%) was determined by the IQCODE-SF to be cognitively impaired before trauma intensive care unit hospitalization. Of the 58 patients studied, 21 (36.2%) had a concussion or skull fracture and 37 (63.8%) had neither. Cognitive impairment was significantly more likely to occur in patients who sustained a concussion or skull fracture than in trauma patients who did not (81% versus 43%; p = 0.006). Patients reported significant depressive symptoms (56%), significant symptoms of posttraumatic stress disorder (38%), and significant symptoms of anxiety (29%). Quality of life scores were lower than in the general United States population and employment difficulties were widespread. A total of 34% of patients reported being unemployed at follow-up, and cognitive impairment was more common among these patients compared with patients in the workforce (p = 0.03). Neither cognitive impairment nor emotional dysfunction was associated with age, sex, race, Injury Severity Score, blood loss, ventilatory days, or intramedullary nailing of long-bone fractures.

CONCLUSIONS

The majority of trauma survivors without intracranial hemorrhage display persistent cognitive impairment, which is nearly twice as likely in those with skull fractures or concussions. This cognitive impairment was associated with functional defects, poor quality of life, and an inability to return to work. Future research must delineate modifiable risk factors for these poor outcomes, especially in patients with skull fractures and concussions, to help improve long-term cognitive and functional status.

Epidemiology and Outcomes of Acute Lung Injury

Acute lung injury (ALI) and its presentation with more severe hypoxemia, the ARDS, is a challenging entity for clinical investigation because, like many critical illness syndromes, it lacks an accepted diagnostic test and relies on a constellation of clinical findings for diagnosis. Despite these barriers, there have been important advances in the clinical and population epidemiology of ALI. This article will review recent studies of the incidence, diagnosis, etiologic and prognostic factors, relevant disease subsets, mortality, and long-term outcomes of ALI. A detailed understanding of the epidemiology and outcomes of ALI is essential for future research on mechanisms of both the acute presentation and long-term sequelae, for designing studies to identify genetic risk factors for developing ALI, and to develop strategies to treat or prevent the morbidity encountered by survivors.

Predicting late anemia in critical illness

Introduction

Identifying critically ill patients most likely to benefit from pre-emptive therapies will become increasingly important if therapies are to be used safely and cost-effectively. We sought to determine whether a predictive model could be constructed that would serve as a useful decision support tool for the pre-emptive management of intensive care unit (ICU)-related anemia.

Methods

Our cohort consisted of all ICU patients (n = 5,170) admitted to a large tertiary-care academic medical center during the period from 1 July 2000 to 30 June 2001. We divided the cohort into development (n = 3,619) and validation (n = 1,551) sets. Using a set of demographic and physiologic variables available within six hours of ICU admission, we developed models to predict patients who either received late transfusion or developed late anemia. We then constructed a point system to quantify, within six hours of ICU admission, the likelihood of developing late anemia.

Results

Models showed good discrimination with receiver operating characteristic curve areas ranging from 0.72 to 0.77, although predicting late transfusion was consistently less accurate than predicting late anemia. A five-item point system predicted likelihood of late anemia as well as existing clinical trial inclusion criteria but resulted in pre-emptive intervention more than two days earlier.

Conclusion

A rule-based decision support tool using information available within six hours of ICU admission may lead to earlier and more appropriate use of blood-sparing strategies.

Brain dysfunction in critically ill patients--the intensive care unit and beyond

Critical care physicians often find themselves prognosticating for their patients, attempting to predict patient survival as well as disability. In the case of neurologic injury, this can be especially difficult. A frequent cause of coma in the intensive care unit is resuscitation following cardiac arrest, for which mortality and severe neurologic disability remain high. Recent studies of the clinical examination, of serum markers such as neuron-specific enolase, and of somatosensory evoked potentials allow accurate and specific prediction of which comatose patients are likely to suffer a poor outcome. Using these tools, practitioners can confidently educate the family for the majority of patients who will die or remain comatose at 1 month. Delirium is a less dramatic form of neurologic injury but, when sought, is strikingly prevalent. In addition, delirium in the intensive care unit is associated with increased mortality and poorer functional recovery, prompting investigation into preventative and therapeutic strategies to counter delirium. Finally, neurologic damage may persist long after the patient's recovery from critical illness, as is the case for cognitive dysfunction detected months and years after critical illness. Psychiatric impairment including depression or post-traumatic stress disorder may also arise. Mechanisms contributing to each of these entities are reviewed.

Epidemiology of depression and antidepressant therapy after acute respiratory failure

The authors enrolled 277 subjects with acute respiratory failure to describe the epidemiology of depressive disorders and antidepressant use during and after intensive care. By SCID criteria, the prevalence of major depressive episode at 2 months was 16%, and 16% had depressive disorder not otherwise specified. Mood disorder incidence was 25% or 28%, depending on methodology. Pre-ICU physical functioning and depression were associated with 2- and 6-month depression severity. At 2 months, the prevalence of antidepressant medication use was 49%, and the incidence was 28%. Depression and antidepressant pharmacotherapy are frequent during recovery from acute respiratory failure.