Post-ICU syndrome: Rescuing the undiagnosed

The effect of an improved ICU physical environment on outcomes and post-ICU recovery-a protocol

BACKGROUND

Intensive care medicine continues to improve, with advances in technology and care provision leading to improved patient survival. However, this has not been matched by similar advances in ICU bedspace design. Environmental factors including excessive noise, suboptimal lighting, and lack of natural lights and views can adversely impact staff wellbeing and short- and long-term patient outcomes. The personal, social, and economic costs associated with this are potentially large. The ICU of the Future project was conceived to address these issues. This is a mixed-method project, aiming to improve the ICU bedspace environment and assess impact on patient outcomes. Two innovative and adaptive ICU bedspaces capable of being individualised to patients' personal and changing needs were co-designed and implemented. The aim of this study is to evaluate the effect of an improved ICU bedspace environment on patient outcomes and operational impact.

METHODS

This is a prospective multi-component, mixed methods study including a randomised controlled trial. Over a 2-year study period, the two upgraded bedspaces will serve as intervention beds, while the remaining 25 bedspaces in the study ICU function as control beds. Study components encompass (1) an objective environmental assessment; (2) a qualitative investigation of the ICU environment and its impact from the perspective of patients, families, and staff; (3) sleep investigations; (4) circadian rhythm investigations; (5) delirium measurements; (6) assessment of medium-term patient outcomes; and (7) a health economic evaluation.

DISCUSSION

Despite growing evidence of the negative impact the ICU environment can have on patient recovery, this is an area of critical care medicine that is understudied and commonly not considered when ICUs are being designed. This study will provide new information on how an improved ICU environment impact holistic patient recovery and outcomes, potentially influencing ICU design worldwide.

TRIAL REGISTRATION

ACTRN12623000541606. Registered on May 22, 2023. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385845&isReview=true .

Comparison of the Incidence of Post-intensive Care Syndrome (PICS) Between Elderly and Non-elderly Patients: A Subgroup Analysis of the Japan-PICS Study

AIM

The aging society is expanding, and more elderly patients are admitted to intensive care units (ICUs). Elderly patients may have increased ICU mortality and are thought to have a high incidence of post-intensive care syndrome (PICS). There are few studies of PICS in the elderly. This study hypothesized that the elderly have an increased incidence of PICS compared to the non-elderly.

METHODS

This is a subgroup analysis of a previous multicenter prospective observational study (Prevalence of post-intensive care syndrome among Japanese intensive care unit patients: The Japan-PICS study) conducted from April 2019 to September 2019. Ninety-six patients were included who were over 18 years old, admitted to the ICU, and expected to require mechanical ventilation for more than 48 hours. Physical component scales (PCS), mental component scales (MCS), and Short-Memory Questionnaire (SMQ) scores of included patients were compared before admission to the ICU and six months later. The diagnosis of PICS required one of the following: (1) the PCS score decreased ≧10 points, (2) the MCS score decreased ≧10 points, or (3) the SMQ score decreased by >40 points. Patients were classified as non-elderly (<65 years old) or elderly (≧65 years old), and the incidence of PICS was compared between these two groups.

RESULTS

The non-elderly (N=27) and elderly (N=69) groups had incidences of PICS: 67% and 62% (p=0.69), respectively.

CONCLUSION

There is no statistically significant difference in the incidence of PICS in the non-elderly and elderly.

Severity classification and influencing variables of the Postintensive Care Syndrome

OBJECTIVE

The study aims to characterise Postintensive Care Syndrome by classifying the severity of the disease and identifying the variables of influence in two highly complex intensive care units for adults in Colombia.

METHODS

A descriptive, cross-sectional, prospective study was carried out to characterise survivors of critical illness using the Healthy Aging Brain Care -Monitor in a sample of 135 patients. Postintensive Care Syndrome severity was classified using Gaussian Mixture Models for clustering, and the most influencing variables were identified through ordinal logistic regression.

RESULTS

Clustering based on Gaussian Mixture Models allowed the classification of Postintensive Care Syndrome severity into mild, moderate, and severe classes, with an Akaike Information Criterion of 308 and an area under the curve of 0.80, which indicates a good fit; Thus, the mild class was characterised by a score on the HABC-M Total scale ≤9; the moderate class for a HABC-M Total score ≥10 and ≤42 and the severe class for a HABC-M Total score ≥43. Regarding the most influencing variables, the probability of belonging to the moderate or severe classes was related to male sex (91%), APACHE II score (22.5%), age (13%), intensive care units days of stay (10.6%), the use of sedation, analgesia and neuromuscular blockers.

CONCLUSION

Intensive care units survivors were characterised using the Healthy Aging Brain Care-Monitor scale, which made it possible to classify Postintensive Care Syndrome through Gaussian Mixture Models clustering into mild, moderate, and severe and to identify variables that had the major influence on the presentation of Postintensive Care Syndrome.

Association Between Mobilization Level And Activity of Daily Living Independence in Critically Ill Patients

OBJECTIVE

To examine the association between the mobilization level during intensive care unit (ICU) admission and independence in activity of daily living (ADL), defined as Barthel Index (BI)≥70.

METHODS

This was a post-hoc analysis of the EMPICS study involving nine hospitals. Consecutive patients who spend >48 hours in the ICU were eligible for inclusion. Mobilization was performed at each hospital according to the shared protocol and the highest ICU mobility score (IMS) during the ICU stay, baseline characteristics, and BI at hospital discharge. Multiple logistic regression analysis, adjusted for baseline characteristics, was used to deter-mine the association between the highest IMS (using the receiver operating characteristic [ROC]) and ADL.

RESULTS

Of the 203 patients, 143 were assigned to the ADL independence group and 60 to the ADL dependence group. The highest IMS score was significantly higher in the ADL independence group than in the dependence group and was a predictor of ADL independence at hospital discharge (odds ratio, 1.22; 95% confidence interval, 1.07-1.38; adjusted p=0.002). The ROC cutoff value for the highest IMS was 6 (specificity, 0.67; sensitivity, 0.70; area under the curve, 0.69).

CONCLUSION

These results indicate that, in patients who were in the ICU for more than 48 hours, that patients with good function in the ICU also exhibit good function upon discharge. However, prospective, multicenter trials are needed to confirm this conclusion.

Ten Years Later, Alarm Fatigue Is Still a Safety Concern

Ten years after the publication of a landmark article in AACN Advanced Critical Care, alarm fatigue continues to be an issue that researchers, clinicians, and organizations aim to remediate. Alarm fatigue contributes to missed alarms and medical errors that result in patient death, increased clinical workload and burnout, and interference with patient recovery. Led by the American Association of Critical-Care Nurses, national patient safety organizations continue to prioritize efforts to battle alarm fatigue and have proposed alarm management strategies to mitigate the effects of alarm fatigue. Similarly, clinical efforts now use simulation studies, individualized alarm thresholds, and interdisciplinary teams to optimize alarm use. Finally, engineering research efforts have innovated the standard alarm to convey information more effectively for medical users. By focusing on patient and provider safety, clinical workflow, and alarm technology, efforts to reduce alarm fatigue over the past 10 years have been grounded in an evidence-based and personnel-focused approach.

Psychological symptoms in difficult-to-sedate critical care survivors

BACKGROUND

Critical care survivors often experience symptoms of anxiety, depression, or post-traumatic stress disorder (PTSD).

AIMS

To determine the prevalence and severity of psychological symptoms during the first 6 months after discharge from the intensive care unit (ICU) and to evaluate its association with patients who are difficult to sedate during admission.

DESIGN

Descriptive, prospective analysis of psychological symptoms in survivors from medicosurgical ICU over a 2-year period.

METHODS

All ICU survivors who required mechanical ventilation (MV) for more than 24 hours were followed for 6 months after their ICU discharge. ICU outcome and complications as well as the presence of psychological symptoms, 1 to 3 to 6 months after discharge were prospectively evaluated through phone interviews comparing the incidence and intensity of patients who were difficult to sedate during their ICU stay with those who were not. Descriptive analysis and multivariate logistic regression were performed.

RESULTS

Data were obtained for 195 patients, of whom 30% experienced difficult sedation (DS). Difficult-to-sedate patients were younger (P = .001), less critically ill (APACHE II score P = .002), and more likely to engage in harmful use of alcohol (P = .001) and psychoactive/psychotropic drug abuse. They also spent longer times on MV and in the ICU (P = .001). Anxiety incidence at 1 to 3 to 6 months post-discharge was significantly higher in DS patients than in those who were not (87.7% vs 45.4%, 75.5% vs 29.0%, and 70.8% vs 23.7%; P < .01), respectively. Depression incidence was also significantly higher in the DS group (82.4% vs 43.1%, 66% vs 33.9%, and 60.4% vs 27.2%; [P = .001]) at 1 to 3 to 6 months, respectively. A higher percentage of patients in the DS group reported symptoms of PTSD at 1 month (28.1% vs 11.5%) (P = .007) when compared with non-DS group.

CONCLUSIONS

Critical care survivors who are difficult to sedate during their ICU stay are more likely to present psychological sequelae. Early identification of at-risk patients is necessary to implement appropriate preventive strategies.

RELEVANCE TO CLINICAL PRACTICE

Patients who are difficult to sedate in the ICU may develop psychological disorders upon discharge, which may negatively affect their recovery. The prevention of DS and the early detection of psychological disorders are essential to minimize its subsequent impact.

Health-related quality of life among critically ill patients after discharge from the ICU-A systematic review protocol

The impact of critical illness on patients is profound, resulting in physical, mental, and social consequences and poor health-related quality of life (HRQOL). Several studies investigated HRQOL among patients discharged from the intensive care unit (ICU). However, few systematic reviews cover studies conducted in the last decade or using valid instruments for measuring HRQOL in general ICU survivor populations. Herein, we conduct a systematic review of these studies that followed PRISMA guidelines. We will search PubMed, Web of Science, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane Library, and Open Grey for papers. We will search for articles reporting the HRQOL of ICU survivors that were written in English and published from 01 January 2012 onward from the date of this protocol's publication. We will also extract HRQOL data and analyze associate factors. The risk of bias will be measured with a standard quality assessment tool. The strength of the results will depend on the number of studies and the consistency of their results. Trial registration number: PROSPERO CRD 42022304279.

Neuropsychiatric Outcomes in Intensive Care Unit Survivors

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Predictors of neurocognitive and psychological disorders in children after intensive care admission: A prospective cohort study

Background and Aims

Children admitted in the pediatric intensive care unit (PICU) often deal with long-term morbidities affecting physical, cognitive, emotional, social, and psychiatric symptoms. We aimed to identify the internal and external factors which predict the occurrence of neurocognitive and psychological disorders in survivors at 3 months after PICU discharge.

Methods

We identified 53 critically ill children, ages 4-18 years old, admitted in PICU for more than 24 h, and survived. We evaluated neurocognitive disorder with Pediatric Cerebral Perfomance Category (PCPC) and psychological disorders with Strengths and Difficulties Questionnaire (SDQ) at the time of PICU discharge and repeated in 3 months afterward. We evaluated the internal and external risk factors related to neurocognitive and psychological disorders in PICU survivors. The internal risk factors were age, gender, family composition, and socioeconomic status. The external risk factors were: surgical intervention, neurological disease, predicted death rate by pediatric index mortality (PIM)-2 score, PICU length of stay (LOS), days of mechanical ventilation, and the number of therapeutic interventions.

Results

There were significant improvement in neurocognitive disorders (p < 0.001), peer problems, (p = 0.01), and prosocial behaviors (p = 0.00) in children at 3 months after the PICU discharge. Age of 4-5 years has a significant effect on neurocognitive disorders (p = 0.04), while male gender (p = 0.02), low-social economy, non-intact family composition (p = 0.01), neurological disease (p = 0.04), surgical intervention (p = 0.01), and TISS score (p = 0.00) have a significant effect on psychological disorders in children at 3 months after the PICU discharge.

Conclusion

Neurocognitive disorders, peer problems, and prosocial behaviors improved in a few patients 3 months after PICU discharge. Age of 4-5 years was a risk factor of the persisted neurocognitive disorder, whereas male gender, low-social economy, non-intact family composition, neurological disease, surgical intervention, and TISS score were risk factors of persisted psychological disorder at 3 months after PICU.

Family experiences and perceptions of intensive care unit care and communication during the COVID-19 pandemic

INTRODUCTION

In 2020, during the first wave of the COVID-19 pandemic in Melbourne, visitor access to acute hospitals including intensive care units (ICUs) was initially barred, followed by a limit of one person per patient for one hour per day. This study explores the care and communication experienced by family members of ICU patients during this time.

METHODS

This qualitative descriptive study was conducted at an Australian quaternary hospital. Semistructured phone interviews were conducted using an aide-memoire designed to understand participants' experiences as family of a patient during this time. Interviews were recorded, transcribed, and thematically analysed.

FINDINGS

Twenty family members of patients in the ICU participated. Three major themes were identified: 'impact of restricting visiting procedures', 'family experiences of communication', and 'care and support'. Inflexible visiting restrictions had a momentous impact on families. Participants objected to having to nominate only two people to visit during the admission and the short visiting time limit. Some family members suffered extreme stress and anxiety during their absence from the bedside. Additional challenges were experienced by rural families, visitors with disabilities, and the young children of patients who were excluded. Communication with clinicians varied. Telehealth was valued by some but not universally embraced. The relationship between staff members and families and involvement in decision-making were unaffected.

CONCLUSION

Families experienced significant psychological distress from being separated from their critically ill relatives. Patient care and involvement in decision-making appeared to be unchanged, but communication with staff felt to be lacking. Better alternatives to face-to-face communication must be sought to limit the impact of family separation on mental health. Families are a key link between the patient and clinicians and often play a major role in patient support and recovery after discharge. There is an urgent need to support them and facilitate meaningful engagement despite the obstacles.

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

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

Association between Early Mobilization in the ICU and Psychiatric Symptoms after Surviving a Critical Illness: A Multi-Center Prospective Cohort Study

This is a prospective multicenter cohort study aiming to investigate the association between early mobilization (EM), defined as a rehabilitation level of sitting at the edge of the bed or higher within 72 h of ICU admission, and psychiatric outcome. Consecutive patients, admitted to the ICU for more than 48 h, were enrolled. The primary outcome was the incidence of psychiatric symptoms at 3 months after hospital discharge defined as the presence of any of three symptoms: depression, anxiety, or post-traumatic stress disorder (PTSD). Risk ratio (RR) and multiple logistic regression analysis were used. As a sensitivity analysis, two methods for inverse probability of treatment weighting statistics were performed. Of the 192 discharged patients, 99 (52%) were assessed. The patients who achieved EM had a lower incidence of psychiatric symptoms compared to those who did not (25% vs. 51%, p-value 0.008, odds ratio (OR) 0.27, adjusted p = 0.032). The RR for psychiatric symptoms in the EM group was 0.49 [95% Confidence Interval, 0.29–0.83]. Sensitivity analysis accounting for the influence of death, loss to follow-up (OR 0.28, adjusted p = 0.008), or potential confounders (OR 0.49, adjusted p = 0.046) consistently showed a lower incidence of psychiatric symptoms in the EM group. EM was consistently associated with fewer psychiatric symptoms.

Posttraumatic stress disorder symptoms after respiratory and cardiovascular emergencies predict risk of hospital readmission: A prospective cohort study

BACKGROUND

Twenty-five percent of patients presenting to the emergency department (ED) for a respiratory or cardiovascular medical emergency develop clinically significant posttraumatic stress disorder (PTSD) symptoms. It is possible that development of PTSD symptoms in this cohort is associated with subsequent adverse physical health events. Our objective was to test whether clinically significant PTSD symptoms 30 days postdischarge are associated with increased risk for hospital readmission within 24 months after discharge among patients presenting to the ED for a respiratory or cardiovascular emergency.

METHODS

This was a prospective cohort study conducted between January 1, 2018, and December 31, 2020, at a U.S. academic medical center, including adult patients presenting with acute respiratory failure or cardiovascular instability requiring a potentially life-sustaining intervention in the ED. PTSD symptoms 30 days postdischarge were measured using the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders-5. The primary outcome was all-cause hospital readmission over the subsequent 24 months after hospital discharge from the index ED visit.

RESULTS

Of the 99 patients included, 73% (95% confidence interval [CI] = 63% to 81%) had a hospital readmission within 24 months. In a multivariable Cox proportional hazards model adjusting for potential confounders (e.g., age, severity of illness during index ED visit, preexisting comorbid conditions) presence of clinically significant PTSD symptoms at 30 days was independently associated with increased risk for all-cause hospital readmission at 24 months (hazards ratio = 2.19, 95% CI = 1.30 to 3.69). These results remained statistically significant across multiple sensitivity analyses.

CONCLUSIONS

Hospital readmission is common among survivors of acute respiratory failure and cardiovascular instability, and PTSD symptoms 30 days postdischarge are an independent predictor of hospital readmission. Survivors of medical emergencies may warrant follow-up evaluation for PTSD symptoms, and future research is warranted to better understand the relationship between psychological trauma and hospital readmission.

Pain Management and COVID-19: A Latin American Perspective

Vaccinations and therapeutics have been developed for COVID-19, but vaccine uptake varies markedly among countries. Public health responses have also varied, in particular, with lockdown efforts and school closing. All over the world, the pandemic exposed healthcare and economic weaknesses. COVID-19 exacerbated mental health issues by exposing the population to prolonged periods of fear, anxiety, financial stress, psychological uncertainties, and sometimes isolation from even family and friends. Chronic pain patients have been disproportionately affected. The pandemic-associated stresses may have exacerbated their already painful symptoms while at the same time interrupting their access to care. The ramifications of the COVID-19 post-viral syndrome (“long COVID-19”) are not yet known. COVID-19 viral infection has been associated with neuropathic pain symptoms. Tele-triage and telehealth applications can help manage chronic pain patients in the COVID-19 era, but many interventional procedures, injections, or other treatments have been delayed. The role of palliative care for patients with terminal cases of infection must be re-examined. Palliative care is a relatively new medical specialty and allows terminally ill patients to die in as much comfort and peace as can be afforded to them. More training in palliative care for all clinicians is urgently needed. COVID-19 exposed much that is wrong or weak or inadequate in our healthcare systems, but it also allowed us to embrace new technologies and develop better systems to manage the challenge of a pandemic.

Emerging Knowledge of the Neurobiology of COVID-19

Many patients with COVID-19 will experience acute or longer-term neuropsychiatric complications. The neurobiological mechanisms behind these are beginning to emerge; however, the neurotropic hypothesis is not strongly supported by clinical data. The inflammatory response to SARS-CoV-2 is likely to be responsible for delirium and other common acute neuropsychiatric manifestations. Vascular abnormalities such as endotheliopathies contribute to stroke and cerebral microbleeds, with their attendant neuropsychiatric sequelae. Longer-term neuropsychiatric syndromes fall into 2 broad categories: neuropsychiatric deficits occurring after severe (hospitalized) COVID-19 and "long COVID," which occurs in many patients with a milder acute COVID-19 illness.

Occupational therapy service provision in adult intensive care units in Australia: A survey of workload practices, interventions and barriers

INTRODUCTION

Occupational therapy practice within intensive care units (ICUs) is limited with respect to published research evidence and guidelines regarding scope of practice. An understanding of the current level of service provision, feasibility of services in ICUs and training and development needs of occupational therapists is required to enable consistent best practice and promote the occupational therapy profile. This study aimed to explore occupational therapy practice within ICUs in Australia including the barriers and enablers to practice perceived by occupational therapists.

METHODS

In this cross-sectional study, a national customised online survey was completed by registered occupational therapists who provide services in intensive care settings in Australia. Recruitment was from July to September 2019 through Occupational Therapy Australia and other professional networks and interest groups.

RESULTS

The survey was completed by 43 respondents. The majority were experienced therapists from Queensland with greater than 10-years post-qualification and working in a tertiary hospital setting. The most common length of time spent working in the ICU was 0-2 h per week. Formal and informal self-care measures, cognitive screens and physical outcome measures were commonly used. Bed-based grooming retraining, pressure care management, functional upper limb retraining and passive ranging were the most frequent interventions provided on a daily basis. Perceived barriers to occupational therapy service provision in ICU included lack of funding for staffing, competing workload demands, lack of occupational therapy role delineation and scope of practice and lack of published evidence and training.

CONCLUSION

Occupational therapy services in intensive care settings in Australia are limited. Published practice guidelines, further research, applications for service funding and ongoing education of the ICU multidisciplinary team regarding the scope of occupational therapy practice are recommended to promote the development of occupational therapy services in ICU.

Neuropathic Pain in Neurologic Disorders: A Narrative Review

Neuropathic pain is defined as a painful condition caused by neurological lesions or diseases. Sometimes, neurological disorders may also be associated with neuropathic pain, which can be challenging to manage. For example, multiple sclerosis (MS) may cause chronic centralized painful symptoms due to nerve damage. Other chronic neuropathic pain syndromes may occur in the form of post-stroke pain, spinal cord injury pain, and other central pain syndromes. Chronic neuropathic pain is associated with dysfunction, disability, depression, disturbed sleep, and reduced quality of life. Early diagnosis may help improve outcomes, and pain control can be an important factor in restoring function. There are more than 100 different types of peripheral neuropathy and those involving sensory neurons can provoke painful symptoms. Accurate diagnosis of peripheral neuropathy is essential for pain control. Further examples are represented by gluten neuropathy, which is an extraintestinal manifestation of gluten sensitivity and presents as a form of peripheral neuropathy; in these unusual cases, neuropathy may be managed with diet. Neuropathic pain has been linked to CoronaVirus Disease (COVID) infection both during acute infection and as a post-viral syndrome known as long COVID. In this last case, neuropathic pain relates to the host’s response to the virus. However, neuropathic pain may occur after any critical illness and has been observed as part of a syndrome following intensive care unit hospitalization.

Intensive care unit-acquired weakness: Questions the clinician should ask

Intensive care unit (ICU)-acquired weakness (ICU-AW) is defined as clinically detected weakness in critically ill patients in whom there is no plausible etiology other than critical illness. Using electrophysiological methods, patients with ICU-AW are classified in three subcategories: critical illness polyneuropathy, critical illness myopathy and critical illness neuromyopathy. ICU-AW is a frequent complication occurring in critical ill patients. Risk factors include illness severity and organ failure, age, hyperglycemia, parenteral nutrition, drugs and immobility. Due to short- and long-term complications, ICU-AW results in longer hospital stay and increased mortality. Its management is essentially preventive avoiding modifiable risk factors, especially duration of sedation and immobilization that should be as short as possible. Pharmacological approaches have been studied but none have proven efficacy. In the present review, we propose practical questions that the clinician should ask in case of acquired weakness during ICU stay: when to suspect ICU-AW, what risk factors should be identified, how to diagnose ICU-AW, what is the prognosis and how can recovery be improved?

Nonopioid analgesics for analgesia in critically ill patients: Friends, enemies, or collaborators

Patients in intensive care units (ICUs) experience pain, which they describe as a significant cause of stress during treatment. It can progress to chronic pain and significantly affect the quality of life. Opioids have long been the backbone of ICU pain therapy. The consequences of their long-term use are known today, such as prolonged ICU stay and mechanical ventilation, resulting in increased treatment costs. Additionally, abstinence syndrome is a consequence of abrupt opioid withdrawal. Also, there is a risk of tolerance and hyperalgesia after prolonged opioid use. Globally, opioid dependence after hospital opioid treatment is alarming, although there is still a lack of data on its incidence after ICU. Multimodal analgesia enables comfort to the patient, opioid-sparing, and avoidance of side effects of non-opioid analgesics. Nonsteroidal anti-inflammatory drugs (NSAIDs) are a broad group of drugs recommended with paracetamol to treat mild to moderate acute postoperative pain. Although often prescribed by intensivists, their use in treating painful conditions in ICU is controversial due to the possible consequences on the organs of critically ill patients. Due to the inhibition of cyclooxygenases, NSAIDs indirectly cause vasoconstriction of the renal arteries and arterioles, leading to kidney damage. NSAIDs inhibit platelet aggregation and may predispose to bleeding. Analgesia of a critically ill patient is a important part of their treatment, however it can be challenging in certain patients. Numerous combinations of pharmacological and non-pharmacological approaches can be adapted to the patient's current characteristics.

Características del síndrome post cuidado intensivo: revisión de alcance

Objetivo: identificar la evidencia disponible de las características del síndrome post unidad de cuidado intensivo en el paciente que egresa de la unidad de cuidado intensivo. Método: revisión de alcance con la metodología del Joanna Briggs Institut, en cinco bases de datos con la estrategia de búsqueda ([PostIntensive AND Care AND Syndrome] [Nursing AND Care AND PICS]). Se incluyeron estudios primarios publicados entre los años 2010 y 2020, disponibles en texto completo. Resultados: después del análisis de los 48 estudios primarios se extrajeron seis categorías temáticas así: aspecto cognitivo en el síndrome post UCI, osteomusculares, psicoemocionales, estrategias de prevención con modelos de sobrevivientes de UCI, síndrome post unidad cuidado intensivo en la familia y herramientas de evaluación. Conclusiones: mejorar la calidad de atención de los pacientes que presentan este síndrome, prevenir la aparición y aumentar la calidad de vida prestada a los sobrevivientes de UCI y sus familias. La evidencia reporta que entre los cuidadores se pueden desencadenar distintos trastornos que disminuyen su calidad de vida. La enfermería juega un papel crucial en la prevención de la aparición del síndrome mediante estrategias en la UCI e interdisciplinares; los planes de egreso y seguimiento a los pacientes pueden lograr que estos se rehabiliten más rápido y eviten discapacidades o secuelas a largo plazo.

Delirium in Intensive Care

Purpose of Review

Delirium in the intensive care unit (ICU) has become increasingly acknowledged as a significant problem for critically ill patients affecting both the actual course of illness as well as outcomes. In this review, we focus on the current evidence and the gaps in knowledge.

Recent Findings

This review highlights several areas in which the evidence is weak and further research is needed in both pharmacological and non-pharmacological treatment. A better understanding of subtypes and their different response to therapy is needed and further studies in aetiology are warranted. Larger studies are needed to explore risk factors for developing delirium and for examining long-term consequences. Finally, a stronger focus on experienced delirium and considering the perspectives of both patients and their families is encouraged.

Summary

With the growing number of studies and a better framework for research leading to stronger evidence, the outcomes for patients suffering from delirium will most definitely improve in the years to come.

Physical, Mental, and Cognitive Health Status of ICU Survivors Before ICU Admission: A Cohort Study

OBJECTIVES

Although patient's health status before ICU admission is the most important predictor for long-term outcomes, it is often not taken into account, potentially overestimating the attributable effects of critical illness. Studies that did assess the pre-ICU health status often included specific patient groups or assessed one specific health domain. Our aim was to explore patient's physical, mental, and cognitive functioning, as well as their quality of life before ICU admission.

DESIGN

Baseline data were used from the longitudinal prospective MONITOR-IC cohort study.

SETTING

ICUs of four Dutch hospitals.

PATIENTS

Adult ICU survivors (n = 2,467) admitted between July 2016 and December 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients, or their proxy, rated their level of frailty (Clinical Frailty Scale), fatigue (Checklist Individual Strength-8), anxiety and depression (Hospital Anxiety and Depression Scale), cognitive functioning (Cognitive Failure Questionnaire-14), and quality of life (Short Form-36) before ICU admission. Unplanned patients rated their pre-ICU health status retrospectively after ICU admission. Before ICU admission, 13% of all patients was frail, 65% suffered from fatigue, 28% and 26% from symptoms of anxiety and depression, respectively, and 6% from cognitive problems. Unplanned patients were significantly more frail and depressed. Patients with a poor pre-ICU health status were more often likely to be female, older, lower educated, divorced or widowed, living in a healthcare facility, and suffering from a chronic condition.

CONCLUSIONS

In an era with increasing attention for health problems after ICU admission, the results of this study indicate that a part of the ICU survivors already experience serious impairments in their physical, mental, and cognitive functioning before ICU admission. Substantial differences were seen between patient subgroups. These findings underline the importance of accounting for pre-ICU health status when studying long-term outcomes.

Persistent Symptoms and Association With Inflammatory Cytokine Signatures in Recovered Coronavirus Disease 2019 Patients

Background

The complications and sequelae of coronavirus disease 2019 (COVID-19) and their effect on long-term health are unclear, and the trajectory of associated immune dysregulation is poorly understood.

Methods

We conducted a prospective longitudinal multicenter cohort study at 4 public hospitals in Singapore. Patients with COVID-19 were monitored for a median of 6 months after recovery from acute infection. Clinical symptoms and radiologic data were collected, along with plasma samples for quantification of immune mediators. The relationship between clinical symptoms and immune cytokine profiles was investigated.

Results

Two hundred eighty-eight participants were recruited, and follow-up data were available for 183, 175, and 120 participants at days 30, 90, and 180 postsymptom onset, respectively. Symptoms related to COVID-19 were present in 31 (16.9%), 13 (7.4%), and 14 (11.7%) at days 30, 90, and 180. In a multivariable model, age >65 years, non-Chinese ethnicity, and the severity of acute infection were associated with increased likelihood of persistent symptoms. Recovered COVID-19 patients had elevated levels of proinflammatory interleukin (IL)-17A, stem cell factor, IL-12p70, and IL-1β and pro-angiogenic macrophage inflammatory protein 1β, brain-derived neurotrophic factor, and vascular endothelial growth factor at day 180 compared with healthy controls. Higher levels of monocyte chemoattractant protein-1 and platelet-derived growth factor-BB were detected in patients with persistent symptoms, versus symptom-free patients.

Conclusions

Approximately 10% of recovered patients had persistent symptoms 6 months after initial infection. Immune cytokine signatures of the recovered patients reflected ongoing chronic inflammation and angiogenesis. Patients with COVID-19 should be monitored closely for emerging long-term health consequences.

Functional outcomes in the inpatient rehabilitation setting following severe COVID-19 infection

OBJECTIVE

To characterize the functional impairments of a cohort of patients undergoing inpatient rehabilitation after surviving severe COVID-19 illness, in order to better understand the ongoing needs of this patient population.

METHODS

This study consisted of a retrospective chart review of consecutive patients hospitalized for COVID-19 and admitted to a regional inpatient rehabilitation hospital from April 29th to May 22nd, 2020. Patient demographics, clinical characteristics and complications from acute hospitalization were examined. Measures of fall risk (Berg Balance Scale), endurance (6 Minute Walk Test), gait speed (10 Meter Walk Test), mobility (transfer and ambulation independence), cognition, speech and swallowing (American Speech and Hearing Association National Outcomes Measurement System Functional Communication Measures) were assessed at rehabilitation admission and discharge.

RESULTS

The study population included 29 patients and was 70% male, 58.6% white and with a mean age of 59.5. The mean length of acute hospitalization was 32.2 days with a mean of 18.7 days intubated. Patients spent a mean of 16.7 days in inpatient rehabilitation and 90% were discharged home. Patients demonstrated significant improvement from admission to discharge in measures of fall risk, endurance, gait speed, mobility, cognition, speech and swallowing, (p< 0.05). At discharge, a significant portion of the population continued to deficits in cognition (attention 37%; memory 28%; problem solving 28%), balance (55%) and gait speed (97%).

CONCLUSION

Patients admitted to inpatient rehabilitation after hospitalization with COVID-19 demonstrated deficits in mobility, cognition, speech and swallowing at admission and improved significantly in all of these domains by discharge. However, a significant number of patients exhibited residual deficits at discharge highlighting the post-acute care needs of this patient population.

Safety of arterial catheterization using the distal radial approach in intensive care unit management: A pilot study

BACKGROUND

Arterial catheter (A-line) is essential for managing severely ill patients, and the radial artery is the most common insertion site in the intensive care unit (ICU). However, many accidental removals occur because the insertion site of A-line in the traditional radial approach (TRA) overlaps with the joint flexion. Recent reports have shown no significant difference in the complication rates between coronarography using the distal radial approach (DRA) and that using TRA. However, to date, no report has examined accidental removals of DRA in the ICU. This study aimed to retrospectively evaluate the safety of the DRA A-line in ICU management.

METHODS

This retrospective, descriptive, and observational study enrolled patients who underwent A-line insertion using the DRA at the authors' facility, which is a university hospital with approximately 1100 beds, from January 1, 2019 to August 31, 2019. The participants' clinical data were extracted from their medical records. The primary outcome was the number of accidental removals.

RESULTS

The study included 20 patients with a median age of 70 (interquartile range (IQR): 58.5-77) years: 10 patients with traumas, 6 with cerebral hemorrhages, 2 with gastrointestinal perforations, and 2 with other diagnoses. The number of punctures was 1 in 15 patients, 2 in 4 patients, and 3 in 1 patient. Only 1 patient required ultrasound guidance, whereas 12 patients required the use of guidewires. The median duration after insertion was 3 (IQR 2.5-5.5) days. Accidental removal was noted in only one patient. No other complications were observed during the period from insertion to removal.

CONCLUSIONS

DRA may be a safe option for insertion of a new A-line in the ICU.

A comparison of standard occupational therapy versus early enhanced occupation-based therapy in a medical/surgical intensive care unit: study protocol for a single site feasibility trial (EFFORT-ICU)

BACKGROUND

Admissions to intensive care units (ICUs) are increasing due to an ageing population, and rising incidence of cardiac and respiratory disease. With advances in medical care, more patients are surviving an initial stay in critical care; however, they can experience ongoing health and cognitive limitations that may influence return to baseline function up to a year post-admission. Recent research has focused on the introduction of early rehabilitation within the ICU to reduce long-term physical and cognitive complications. The aim of this study is to explore the feasibility and impact of providing early enhanced occupation-based therapy, including cognitive stimulation and activities of daily living, to patients in intensive care.

METHODS

This study involves a single site randomised-controlled feasibility trial comparing standard occupational therapy care to an early enhanced occupation-based therapy. Thirty mechanically ventilated ICU patients will be recruited and randomly allocated to the intervention or control group. The primary outcome measure is the Functional Independence Measure (FIM), and secondary measures include the Modified Barthel Index (MBI), Montreal Cognitive Assessment (MoCA), grip strength, Hospital Anxiety and Depression Scale (HADS) and Short-Form 36 Health survey (SF-36). Measures will be collected by a blind assessor at discharge from intensive care, hospital discharge and a 90-day follow-up. Daily outcome measures including the Glasgow Coma Scale (GCS), Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Measure for intensive care units (CAM-ICU) will be taken prior to treatment. Participants in the intervention group will receive daily a maximum of up to 60-min sessions with an occupational therapist involving cognitive and functional activities such as self-care and grooming. At the follow-up, intervention group participants will be interviewed to gain user perspectives of the intervention. Feasibility data including recruitment and retention rates will be summarised descriptively. Parametric tests will compare outcomes between groups. Interview data will be thematically analysed.

DISCUSSION

This trial will provide information about the feasibility of investigating how occupational therapy interventions in ICU influence longer term outcomes. It seeks to inform the design of a phase III multicentre trial of occupational therapy in critical care general medical intensive care units.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000374268 ; prospectively registered on 13 March 2018/ https://www.anzctr.org.au Trial funding: Metro South Health Research Support Scheme Postgraduate Scholarship.

Improving Rehabilitation Information-Giving to Intensive Care Unit Survivors to Aid in Physical and Psychological Recovery

Intensive care unit (ICU) survivors have an increased mortality rate and reduced quality of life associated with post-ICU syndrome: a triad of physical, psychiatric and cognitive decline. Following evidence on the benefits of early rehabilitation, the National Institute of Clinical Excellence (NICE) CG83 guidelines instruct the provision of rehabilitation information to ICU patients before discharge. Only 33% of UK trusts meet these guidelines. The aim of this project was to reach 100% patient and ICU therapist satisfaction with the rehabilitation information given before ICU discharge at Medway Maritime Hospital, within four months. Patient and therapist satisfaction was assessed using questionnaires at baseline and following each Plan-Do-Study-Act (PDSA) cycle. In PDSA1, a generalised rehabilitation information booklet was created and distributed to ICU survivors pre-discharge. For PDSA2, a personalised rehabilitation plan completed by therapists was added. During PDSA3, the booklet was enriched with mental health and speech and language therapy sections. Results showed a shift in patient satisfaction scores, indicating a significant change in the median from 20% at baseline to 87% after PDSA3. This was also reflected in the therapist satisfaction scores, which increased significantly from 60% at baseline to 100%. The introduction of a generalised information booklet, supplemented with a personalised recovery plan, is an effective way of increasing critical care patient and therapist satisfaction with post-discharge rehabilitation information provision. This should translate to greater patient engagement with rehabilitation and improved long-term outcomes. This is ever more pertinent, as the COVID-19 pandemic will exponentially increase the numbers of ICU survivors at risk of long-term morbidity and mortality.

The FRAIL-FIT 30 Study – Factors influencing 30-day mortality in frail patients admitted to ICU: A retrospective observational cohort study

Background

Frailty is a multi-dimensional syndrome of reduced reserve, resulting from overlapping physiological decrements across multiple systems. The contributing factors, temporality and magnitude of frailty’s effect on mortality after ICU admission are unclear. This study assessed frailty’s impact on mortality and life sustaining therapy (LST) use, following ICU admission.

Methods

This single-centre retrospective observational cohort study analysed data collected prospectively in Glasgow Royal Infirmary ICU. Of 684 eligible patients, 171 were frail and 513 were non-frail. Frailty was quantified using the Rockwood Clinical Frailty Scale (CFS). All patients were followed up 1-year after ICU admission. The primary outcome was all-cause mortality at 30-days post-ICU admission. Key secondary outcomes included mortality at 1-year and LST use.

Results

Frail patients were significantly less likely to survive 30-days post-ICU admission (61.4% vs 81.1%, p < 0.001). This continued to 1-year (48.5% vs 68.2%, p < 0.001). Frailty significantly increased mortality hazards in covariate-adjusted analyses at 30-days (HR 1.56; 95%CI 1.14–2.15; p = 0.006), and 1-year (HR 1.35; 95%CI 1.03–1.76; p = 0.028). Single-point CFS increases were associated with a 30-day mortality hazard of 1.23 (95%CI 1.13–1.34; p < 0.001) in unadjusted analyses, and 1.11 (95%CI 1.01–1.22; p = 0.026) after covariate adjustment. Frail patients received significantly more days of LST (median[IQR]: 5[3,11] vs 4[2,9], p = 0.008).

Conclusion

Frailty was significantly associated with greater mortality at all time points studied, but most notably in the first 30-days post-ICU admission. This was despite greater LST use. The accrual effect of frailty increased adverse outcomes. Point-by-point use of frailty scoring could allow for more informed decision making in ICU.

Doing time in an Australian ICU; the experience and environment from the perspective of patients and family members

BACKGROUND

The intensive care environment and experiences during admission can negatively impact patient and family outcomes and can complicate recovery both in hospital and after discharge. While their perspectives based on intimate experiences of the environment could help inform design improvements, patients and their families are typically not involved in design processes. Rather than designing the environment around the needs of the patients, emphasis has traditionally been placed on clinical and economic efficiencies.

OBJECTIVE

The main objective was to inform design of an optimised intensive care bedspace by developing an understanding of how patients and their families experience the intensive care environment and its impact on recovery.

METHODS

A qualitative descriptive study was conducted with data collected in interviews with 17 intensive care patients and seven family members at a large cardiothoracic specialist hospital, analysed using a framework approach.

RESULTS

Participants described the intensive care as a noisy, bright, confronting and scary environment that prevented sleep and was suboptimal for recovery. Bedspaces were described as small and cluttered, with limited access to natural light or cognitive stimulation. The limited ability to personalise the environment and maintain connections with family and the outside world was considered especially problematic.

CONCLUSIONS

Intensive care patients described features of the current environment they considered problematic and potentially hindering their recovery. The perspective of patients and their families can be utilised by researchers and developers to improve the design and function of the intensive care environment. This can potentially improve patient outcomes and help deliver more personalised and effective care to this vulnerable patient population and their families.

The intensive care unit environment from the perspective of medical, allied health and nursing clinicians: A qualitative study to inform design of the 'ideal' bedspace

BACKGROUND

While the impact of the intensive care environment on patients' experiences and outcomes has been extensively studied, relatively little research has examined the impact on clinicians and their provision of care in the intensive care unit (ICU). Understanding staff experience and views about the environment is needed to optimise the ICU environment, patient outcomes and staff wellbeing.

OBJECTIVE

The objective of this study was to inform design of an optimised intensive care bedspace by describing clinicians' views about the current environment, including experience, impact on performance of clinical duties, and experience and outcomes of patients and family members.

METHODS

A pragmatic, qualitative descriptive study was conducted, with data collected in focus groups and interviews with 30 intensive care clinicians at a large cardiothoracic specialist hospital and analysed using the framework approach.

RESULTS

Participants acknowledged that the busy and noisy ICU provided a suboptimal healing environment for patients, was confronting for visiting families and exposed clinicians to risk of psychological injury. The bedspace, described as small and cluttered, hindered provision of clinical care of various kinds and contributed to an increased risk of staff physical injuries. Participants noted that the bland, sterile environment, devoid of natural light and views of the outside world, negatively affected both staff and patients' mood and motivation. Aware of the potential benefits of natural light, cognitive stimulation and visually appealing environments for patients and families, clinicians were frustrated by their inability to personalise the bedspace. Some participants, while acknowledging the importance of family contact for patients, were concerned about the impact of visitors on care delivery, particularly within already crowded bedspaces, suggesting restrictions on visiting.

CONCLUSIONS

Intensive care clinicians perceive that the current intensive care environment is suboptimal for patients, their families and staff and may contribute to suboptimal patient outcomes. The intensive care bedspaces need to be redesigned to ensure they are built around the needs of the people using them. Optimisation is dependent on engaging all stakeholders in future design processes.

Sleeping Soundlessly in the Intensive Care Unit

An estimated 70% of patients who have been in the Intensive Care Unit (ICU) experience some form of Post-Intensive Care Syndrome (PICS). As a stressful environment, the ICU can be traumatic for any patient; however, the disruption of sleep experienced by patients in ICU negatively impacts their mental status and recovery. One of the most significant contributors to sleep disruption is the constant blare of monitor alarms, many of which are false or redundant. Through multisensory approaches and procedural redesign, the hostile acoustic environment of the ICU that causes so many to suffer from PICS may be alleviated. In this paper, we present suggestions for improving the ICU acoustic environment to possibly reduce the incidence of post-ICU complications such as PICS.

COVID-19: What do we need to know about ICU delirium during the SARS-CoV-2 pandemic?

In March 2020, the World Health Organisation announced the COVID-19 pandemic caused by the SARS-CoV-2 virus. As well as respiratory failure, the SARS-CoV-2 may cause central nervous system (CNS) involvement, including delirium occurring in critically ill patients (ICU delirium). Due attention must be paid to this subject in the face of the COVID-19 pandemic. Delirium, the detection of which takes less than two minutes, is frequently underestimated during daily routine ICU care, but it may be a prodromal symptom of infection or hypoxia associated with severe respiratory failure. During the COVID-19 pandemic, systematic delirium monitoring using validated tests (CAM-ICU or ICDSC) may be sacrificed. This is likely to be due to the fact that the main emphasis is placed on organisational issues, i.e. the lack of ventilators, setting priorities for limited mechanical ventilation options, and a shortage of personal protective equipment. Early identification of patients with delirium is critical in patients with COVID-19 because the occurrence of delirium may be an early symptom of worsening respiratory failure or of infectious spread to the CNS mediated by potential neuroinvasive mechanisms of the coronavirus. The purpose of this review is to identify problems related to the development of delirium during the COVID-19 epidemic, which are presented in three areas: i) factors contributing to delirium in COVID-19, ii) potential pathophysiological factors of delirium in COVID-19, and iii) long-term consequences of delirium in COVID-19. This article discusses how healthcare workers can reduce the burden of delirium by identifying potential risk factors and difficulties during challenges associated with SARS-CoV-2 infection.

Family ratings of ICU care. Is there concordance within families?

PURPOSE

To examine heterogeneity of quality-of-care ratings within families and to examine possible predictors of concordance.

MATERIALS AND METHODS

We examined two aspects of agreement within families: response similarity and the amount of exact concordance in responses in a cohort of Danish ICU family members participating in a questionnaire survey (the European Quality Questionnaire: euroQ2).

RESULTS

Two hundred seventy-four family respondents representing 122 patients were included in the study. Identical ratings between family members occurred in 28%-59% of families, depending upon the specific survey item. In a smaller sample of 28 families whose patients died, between 39% and 86% gave identical responses to items rating end-of-life care. There was more response variance within than between families, yielding low estimates of intrafamily correlation. Statistics correcting for chance agreement also suggested modest within-family agreement.

CONCLUSIONS

The finding that variance is higher within than between families suggests the value of including multiple participants within a family in order to capture varying points of view.

Development and validation of a questionnaire to measure post-intensive care syndrome

OBJECTIVE

This study aimed to develop a Post-Intensive Care Syndrome Questionnaire (PICSQ) and assess the psychometric properties of PICSQ in intensive care unit survivors.

METHODS

PICSQ items were generated through relevant literature reviews, qualitative interviews among survivors, and multiple rounds of content validity evaluations by experts. Data were collected from 536 survivors at seven health care facilities in three cities of Korea from June to August 2018. The validity and reliability of PICSQ were assessed using exploratory factor analysis, confirmatory factor analysis, internal consistency and correlation coefficients.

RESULTS

The final PICSQ consisted of 18 items. Through exploratory factor analysis, three factors (mental, cognitive and physical) were derived. The reliability of PICSQ was represented by a Cronbach's α of 0.93, while the internal consistency of each factor was good (Cronbach's α = 0.84 to 0.90). The model fit of PICSQ was satisfactory and confirmatory factor analysis demonstrated good convergent and discriminant validity of the questionnaire.

CONCLUSION

Because PICSQ is valid and reliable, it is recommended for use in clinical practice and research to assess post-intensive care syndrome in intensive care survivors.

Mental illness after admission to an intensive care unit

PURPOSE

Survivors of critical illness may be at higher risk of developing subsequent mental illness. We sought to determine the risk of new mental illness diagnoses across a large population of intensive care unit (ICU) survivors compared with hospitalized patients.

METHODS

Population-based study (2005-2015) conducted in adults hospitalized in Ontario, Canada. The primary exposure was ICU admission for ≥ 48 h; secondary exposures were ICU procedures including mechanical ventilation and duration of ICU. The primary outcome was mental illness diagnosed during the year after hospital discharge. To account for case mix differences between ICU and other hospitalized patients, sensitivity analyses were conducted restricting to six pre-specified diagnoses that can lead to hospitalization with or without ICU.

RESULTS

1,847,462 patients survived hospitalization, of whom 121,101 were admitted to ICU for ≥ 48 h. ICU patients had a higher rate of new mental illness diagnoses in the year after discharge compared to hospitalized patients (17 vs. 15%, adjusted hazard ratio (aHR) 1.08, 95% CI 1.07-1.10). In analyses restricted to pre-specified most responsible diagnoses, the increased risk associated with ICU was only significant for patients with pneumonia. Among ICU survivors, exposure to mechanical ventilation (aHR: 1.08; 95% CI 1.05-1.12) or longer ICU stays (aHR: 1.004 per day; 95% CI 1.003-1.005) increased the risk of new mental illness diagnosis.

CONCLUSIONS

ICU was associated with a marginally increased risk of mental illness diagnosis after hospitalization that was often no longer apparent when reason for admission was considered. Patients exposed to mechanical ventilation or longer ICU stays may be at higher risk of subsequent mental illnesses.

Optimizing Post-Intensive Care Unit Rehabilitation

Survivors of intensive care unit (ICU) admission face unique challenges after hospital discharge. In addition to an increased overall mortality and rates of hospital readmission, patients often experience difficulties in physical functioning, cognition, and mental health, which are collectively termed post-intensive care syndrome. To this date, there are no established strategies to address these deleterious outcomes. A number of studies have examined various unique methods to prevent and treat PICS symptoms, including early physical and occupational therapy, providing post-discharge education, or facilitating routine follow up in post-ICU clinics. These trials have yet to demonstrate any substantial or meaningful effect in post-ICU patients and collectively reinforce the need for further research to identify effective intervention for patients who survive critical illness.

Psychogenic stress in hospitalized veterinary patients: Causation, implications, and therapies

OBJECTIVE

To review the sources, adverse effects, diagnosis, treatment, and prevention of psychogenic stress in hospitalized human and veterinary patients.

DATA SOURCES

Data were collected by searching PubMed for veterinary and human literature from the past 10 years.

HUMAN DATA SYNTHESIS

Psychogenic stress has been linked to immune suppression; gastrointestinal, cardiovascular, and cutaneous diseases; delayed wound healing; alterations in pain perception; and neurologic impairment. Sources of psychogenic stress include environmental alterations such as excessive noise and light, social and physical factors, sleep disruption, drugs, and underlying disease. Nonpharmacologic options for stress reduction include environmental and treatment modifications, music therapy, and early mobilization. Pharmacologic options include sedation with benzodiazepines and dexmedetomidine. Trazodone and melatonin have been examined for use in sleep promotion but are not currently recommended as standard treatments in ICU.

VETERINARY DATA SYNTHESIS

Activation of the stress response in veterinary patients is largely the same as in people, as are the affected body systems. Possible sources of stress can include social, physical, and environmental factors. No gold standard currently exists for the identification and quantification of stress. A combination of physical examination findings and the results of serum biochemistry, CBC, and biomarker testing can be used to support the diagnosis. Stress scales can be implemented to identify stressed patients and assess severity. Nonpharmacologic treatment options include low-stress handling, pheromones, environmental modifications, and sleep promotion. Pharmacologic options include trazodone, benzodiazepines, dexmedetomidine, and melatonin.

CONCLUSION

The prevalence and clinical significance of psychogenic stress in hospitalized veterinary patients is unknown. Future studies are needed to specifically examine the causative factors of psychogenic stress and the effects of various therapies on stress reduction. The recognition and reduction of psychogenic stress in veterinary patients can lead to improvements in patient care and welfare.

Organ support therapy in the intensive care unit and return to work: a nationwide, register-based cohort study

PURPOSE

The association between severity of illness and ability to return to work is unclear. Therefore, we investigated return to work and associations with measures of illness severity in ICU survivors.

METHODS

We conducted this cohort study using Danish registry data for the period 2005-2014 on ICU patients who were discharged alive from hospital, had an ICU length of stay (LOS) of at least 72 h, were not treated with dialysis before hospital admission and were working prior to admission. We assessed (1) the cumulative incidence (chance) of return to work (2005-2017) and receipt of social benefits after discharge from a hospital stay with ICU admission and (2) the association between organ support therapies (renal replacement therapy, cardiovascular support and mechanical ventilation), and during 2011-2014 SAPS II and ICU LOS, and return to work, using multivariable Cox regression.

RESULTS

Among 5762 ICU survivors, 68% returned to work within 2 years after hospital discharge. Disability and sickness benefits constituted 89% of social benefits among patients not returning to work and 59% among patients withdrawing from work following an initial return to work. Mechanical ventilation (HR 0.70, 95% CI [0.65-0.77]), but not RRT (HR 0.85, 95% CI [0.71-1.02]), cardiovascular support (HR 0.93, 95% CI [0.82-1.07]) and increasing SAPS II, was associated with decreased chance of return to work. Increasing ICU LOS was also associated with a decreased chance of return to work.

CONCLUSIONS

The majority of a nationwide cohort of ICU survivors returned to work. Sick leave and receipt of disability pension were common following ICU admission. Mechanical ventilation and longer ICU LOS were associated with reduced chances of return to work.

Delirium and effect of circadian light in the intensive care unit: a retrospective cohort study

BACKGROUND

Delirium is a serious condition often experienced by critically ill patients in intensive care units (ICUs). The role of circadian light for this condition is unclear. The aim of this study was to describe incidence of delirium, risk factors for delirium, and the association between delirium and circadian light for patients in the ICU.

METHODS

This is a retrospective cohort study of all patients at a Danish ICU from 1 August 2015 to 31 January 2016. Exclusion criteria were heavy sedation, no Confusion Assessment Method for the ICU (CAM-ICU) scores, or inability to communicate in Danish. Delirium was defined as at least one positive CAM-ICU score or treatment with haloperidol. Three of nine beds at the ICU had a circadian light installation. Allocation to ICU beds with or without circadian light depended on availability at admission. Risk factors for development of delirium were analyzed by simple and multiple logistic regression.

RESULTS

We included 183 patients in the study. The incidence of delirium was 28% (95% CI 22, 35). Allocation to beds with or without circadian lighting was not associated with delirium incidence (OR 1.14; 95% CI 0.55, 2.37; P = 0.73). We found that Simplified Acute Physiology Score II (SAPS II) (OR 1.03; 95% CI 1.01, 1.06; P = 0.002), and dexmedetomidine was associated with delirium (OR 4.14; 95% CI 1.72, 10.03; P = 0.002).

CONCLUSION

In this population of patients admitted to an ICU during 6 months, the incidence of delirium was 28%. We did not find an association between circadian light and development of delirium.

Validity of a single PTSD checklist item to screen for insomnia in survivors of critical illness

BACKGROUND

There is no insomnia screening tool validated in intensive care unit (ICU) survivors.

OBJECTIVES

To examine the validity of a single item from the PTSD checklist-Civilian version (PCL-C) to detect insomnia by Insomnia Severity Index (ISI) METHODS: We performed a secondary analysis of data from a longitudinal investigation in 120 medical-surgical ICU survivors. At 1 year post-ICU, patients completed ISI, PCL-C, and Medical Short-Form 12 (SF-12) by telephone. A single PCL-C item rates difficulty initiating or maintaining sleep over the past month. We compared performance characteristics of this PCL-C item to ISI-defined insomnia (ISI ≥15).

RESULTS

A score of ≥3 on the PCL-C sleep item exhibited 91% sensitivity and 67% specificity for ISI-defined insomnia (ISI ≥ 15), and it demonstrated construct validity by correlation to related QOL indices.

CONCLUSIONS

A single PCL-C sleep item score ≥ 3 is a reasonable screen to identify insomnia symptoms in ICU survivors.

Aging and Post-Intensive Care Syndrome: A Critical Need for Geriatric Psychiatry

Because of the aging of the intensive care unit (ICU) population and an improvement in survival rates after ICU hospitalization, an increasing number of older adults are suffering from long-term impairments because of critical illness, known as post-intensive care syndrome (PICS). This article focuses on PICS-related cognitive, psychological, and physical impairments and the impact of ICU hospitalization on families and caregivers. The authors also describe innovative models of care for PICS and what roles geriatric psychiatrists could play in the future of this rapidly growing population.