Better Measures, Better Trials, Better Outcomes in Survivors of Critical Illness

Family and Support Networks Following Critical Illness

Research highlights the psychosocial impact of critical illness on family who typically adopt a caregiver role to the survivor. We review evidence on informal caregiver psychosocial outcomes and interventional studies designed to improve them. We argue informal caregivers have distinct and complex needs that differ from patients. Interventional studies ought to be designed for this cohort with careful attention paid to the timing of interventions. We consider the influence of social isolation on recovery and discuss service improvement approaches to build social support networks to enhance recovery, where caregivers and survivors are involved in the design of aftercare programs.

Early Mobilization of Patients in Intensive Care: Organization, Communication and Safety Factors that Influence Translation into Clinical Practice

Please change the first sentence to: This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2018. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2018. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

The Association of Frailty With Post-ICU Disability, Nursing Home Admission, and Mortality: A Longitudinal Study

BACKGROUND

Frailty is a strong indicator of vulnerability among older persons, but its association with ICU outcomes has not been evaluated prospectively (ie, with objective measurements obtained prior to ICU admission). Our objective was to prospectively evaluate the relationship between frailty and post-ICU disability, incident nursing home admission, and death.

METHODS

The parent cohort included 754 adults aged ≥ 70 years, who were evaluated monthly for disability in 13 functional activities and every 18 months for frailty (1998-2014). Frailty was assessed using the Fried index, where frailty, prefrailty, and nonfrailty were defined, respectively, as at least three, one or two, and zero criteria (of five). The analytic sample included 391 ICU admissions.

RESULTS

The mean age was 84.0 years. Frailty and prefrailty were present prior to 213 (54.5%) and 140 (35.8%) of the 391 admissions, respectively. Relative to nonfrailty, frailty was associated with 41% greater disability over the 6 months following a critical illness (adjusted risk ratio, 1.41; 95% CI, 1.12-1.78); prefrailty conferred 28% greater disability (adjusted risk ratio, 1.28; 95% CI, 1.01-1.63). Frailty (odds ratio, 3.52; 95% CI, 1.23-10.08), but not prefrailty (odds ratio, 2.01; 95% CI, 0.77-5.24), was associated with increased nursing home admission. Each one-point increase in frailty count (range, 0-5) was associated with double the likelihood of death (hazard ratio, 2.00; 95% CI, 1.33-3.00) through 6 months of follow-up.

CONCLUSIONS

Pre-ICU frailty status was associated with increased post-ICU disability and new nursing home admission among ICU survivors, and death among all admissions. Pre-ICU frailty status may provide prognostic information about outcomes after a critical illness.

Low Levels of Physical Activity During Critical Illness and Weaning: The Evidence-Reality Gap

BACKGROUND

Physical rehabilitation can benefit critically ill patients during intensive care unit (ICU) admission, but routine clinical practice remains inconsistent nor examined in prolonged mechanical ventilation patients transferred to a specialist ventilator weaning unit (VWU). Behavioral mapping is a sampling approach that allows detailed reporting of physical activity profiles. The objective of this study was to characterize the physical activity profile of critically ill patients in a UK ICU and VWU.

METHODS

Single-center, prospective observational study in a university teaching hospital. Patient observations, conducted Monday through Sunday from 08:30 am to 08:00 pm and for 1 minute every 10 minutes, included data points of patient location, people in attendance, and highest level of activity. Descriptive statistics were utilized to analyze and report data.

RESULTS

Forty-two ICU and 11 VWU patients were recruited, with 2646 and 693 observations, respectively, recorded. In the ICU, patients spent a median (interquartile range) of 100% (96%-100%) of the day (10.5 [10.0-10.5] hours) located in bed, with minimal/no activity for 99% (96%-100%) of the day (10.4 [9.7-10.5] hours). Nursing staff were most frequently observed in attendance with patients irrespective of ventilation or sedation status, although patients still spent approximately two-thirds of the day alone. Bed-to-chair transfer was the highest activity level observed. In the VWU, patients spent 94% (73%-100%) of the day (9.9 [7.7-10.5] hours) in bed and 56% (43%-60%) of time alone. Physical activity levels were higher and included ambulation. All physical activities occurred during physical rehabilitation sessions.

CONCLUSIONS

These profiles of low physical activity behavior across both patients in the ICU and VWU highlight the need for targeted strategies to improve levels beyond therapeutic rehabilitation and support for a culture shift toward providing patients with, and engaging them in, a multidisciplinary, multiprofessional environment that optimizes overall physical activity.

Physiotherapy management of intensive care unit-acquired weakness

[Hodgson CL, Tipping CJ (2016) Physiotherapy management of intensive care unit-acquired weakness.Journal of Physiotherapy63: 4-10].