Outcome of ICU survivors: a comprehensive review. The role of patient-reported outcome studies

Tau and Aβ42 in lavage fluid of pneumonia patients are associated with end-organ dysfunction: A prospective exploratory study

BACKGROUND

Bacterial pneumonia and sepsis are both common causes of end-organ dysfunction, especially in immunocompromised and critically ill patients. Pre-clinical data demonstrate that bacterial pneumonia and sepsis elicit the production of cytotoxic tau and amyloids from pulmonary endothelial cells, which cause lung and brain injury in naïve animal subjects, independent of the primary infection. The contribution of infection-elicited cytotoxic tau and amyloids to end-organ dysfunction has not been examined in the clinical setting. We hypothesized that cytotoxic tau and amyloids are present in the bronchoalveolar lavage fluid of critically ill patients with bacterial pneumonia and that these tau/amyloids are associated with end-organ dysfunction.

METHODS

Bacterial culture-positive and culture-negative mechanically ventilated patients were recruited into a prospective, exploratory observational study. Levels of tau and Aβ42 in, and cytotoxicity of, the bronchoalveolar lavage fluid were measured. Cytotoxic tau and amyloid concentrations were examined in comparison with patient clinical characteristics, including measures of end-organ dysfunction.

RESULTS

Tau and Aβ42 were increased in culture-positive patients (n = 49) compared to culture-negative patients (n = 50), independent of the causative bacterial organism. The mean age of patients was 52.1 ± 16.72 years old in the culture-positive group and 52.78 ± 18.18 years old in the culture-negative group. Males comprised 65.3% of the culture-positive group and 56% of the culture-negative group. Caucasian culture-positive patients had increased tau, boiled tau, and Aβ42 compared to both Caucasian and minority culture-negative patients. The increase in cytotoxins was most evident in males of all ages, and their presence was associated with end-organ dysfunction.

CONCLUSIONS

Bacterial infection promotes the generation of cytotoxic tau and Aβ42 within the lung, and these cytotoxins contribute to end-organ dysfunction among critically ill patients. This work illuminates an unappreciated mechanism of injury in critical illness.

Organization, feasibility and patient appreciation of a follow-up consultation in surgical critically ill patients with favorable baseline quality of life and prolonged ICU-stay: a pilot study

OBJECTIVES

Intensive care unit (ICU) survivors are often left with impairments in physical, mental and cognitive functioning (Post-Intensive Care Syndrome (PICS)). We evaluated the organization, the feasibility for caregivers and patients and the patients' appreciation of a post-ICU consultation aiming to detect these PICS-symptoms.

METHODS

A single-center prospective observational pilot study was conducted during an 18 month-period in the surgical ICU of a tertiary care hospital. Consecutive adult patients with an ICU-stay of ≥8 days and a favorable baseline quality of life (utility index ≥0.6 on EQ-5D-3 L) were eligible for inclusion. A post-ICU follow-up consultation consisting of a structured interview was scheduled 3 months after hospital discharge. Characteristics of the consultation (CG) and no consultation group (NCG) were compared. P-values <0.05 were considered significant.

RESULTS

Of 133 eligible patients, 85 (64%) consented for the study and 42 (49%) attended the consultation. A total of 148 phone calls were made to schedule the consultations. Consultations took a median of 68 (61-74) minutes. Compared to CG-patients, NCG-patients were more often discharged to a care facility (P = 0.003) and had more problems with mobility (P = 0.014), self-care (P < 0.001) and usual activities (P = 0.005) after 3 months. At least one PICS-related problem was documented in all patients in the CG and NCG. Thirty-four CG-patients (81%) appreciated the initiative.

CONCLUSION

Organizing an ICU-follow-up consultation was difficult and feasibility was low, but most attending patients appreciated the initiative. Better developed structures for ICU-follow-up are needed in view of the high number of PICS-related problems documented.

Oxidized High-Density Lipoprotein Induces Endothelial Fibrosis Promoting Hyperpermeability, Hypotension, and Increased Mortality

During systemic inflammation, reactive oxygen species (ROS) are generated in the bloodstream, producing large amounts of oxidized HDL (oxHDL). OxHDL loses the vascular protective features of native HDL, acquiring detrimental actions. Systemic inflammation promotes endothelial fibrosis, characterized by adhesion protein downregulation and fibrotic-specific gene upregulation, disrupting endothelial monolayer integrity. Severe systemic inflammatory conditions, as found in critically ill patients in the intensive care unit (ICU), exhibit endothelial hyperpermeability, hypotension, and organ hypoperfusion, promoting organ dysfunction and increased mortality. Because endothelial fibrosis disturbs the endothelium, it is proposed that it is the cellular and molecular origin of endothelial hyperpermeability and the subsequent deleterious consequences. However, whether oxHDL is involved in this process is unknown. The aim of this study was to investigate the fibrotic effect of oxHDL on the endothelium, to elucidate the underlying molecular and cellular mechanism, and to determine its effects on vascular permeability, blood pressure, and mortality. The results showed that oxHDL induces endothelial fibrosis through the LOX-1/NOX-2/ROS/NF-κB pathway, TGF-β secretion, and ALK-5/Smad activation. OxHDL-treated rats showed endothelial hyperpermeability, hypotension, and an enhanced risk of death and mortality, which was prevented using an ALK-5 inhibitor and antioxidant diet consumption. Additionally, the ICU patients showed fibrotic endothelial cells, and the resuscitation fluid volume administered correlated with the plasma oxHDL levels associated with an elevated risk of death and mortality. We conclude that oxHDL generates endothelial fibrosis, impacting blood pressure regulation and survival.

Level of sedation in critically ill adult patients: a protocol for a systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

It is standard of care to provide sedation to critically ill patients to reduce anxiety, discomfort and promote tolerance of mechanical ventilation. Given that sedatives can have differing effects based on a variety of patient and pharmacological characteristics, treatment approaches are largely based on targeting the level of sedation. The benefits of differing levels of sedation must be balanced against potential adverse effects including haemodynamic instability, causing delirium, delaying awakening and prolonging the time of mechanical ventilation and intensive care stay. This systematic review with meta-analysis aims to investigate the current evidence and compare the effects of differing sedation levels in adult critically ill patients.

METHODS AND ANALYSES

We will conduct a systematic review based on searches of preidentified major medical databases (eg, MEDLINE, EMBASE, CENTRAL) and clinical trial registries from their inception onwards to identify trials meeting inclusion criteria. We will include randomised clinical trials comparing any degree of sedation with no sedation and lighter sedation with deeper sedation for critically ill patients admitted to the intensive care unit. We will include aggregate data meta-analyses and trial sequential analyses. Risk of bias will be assessed with domains based on the Cochrane risk of bias tool. An eight-step procedure will be used to assess if the thresholds for clinical significance are crossed, and the certainty of the evidence will be assessed using Grades of Recommendations, Assessment, Development and Evaluation.

ETHICS AND DISSEMINATION

No formal approval or review of ethics is required as individual patient data will not be included. This systematic review has the potential to highlight (1) whether one should believe sedation to be beneficial, harmful or neither in critically ill adults; (2) the existing knowledge gaps and (3) whether the recommendations from guidelines and daily clinical practice are supported by current evidence. These results will be disseminated through publication in a peer-reviewed journal.

Patients' experiences of cognitive impairment following critical illness: a scoping review protocol

INTRODUCTION

Critical illness and admission to an intensive care unit (ICU) can affect patients for months or years following discharge as many suffer from cognitive impairment. Long-term cognitive impairment affects patients' quality of life and ability to adapt to everyday life. Exploring their experiences on how and which cognitive impairments are affecting their everyday lives facilitates planning of relevant research on interventions that may serve to alleviate the burden of post-ICU cognitive impairment. The objective of this scoping review is to map the existing research on patients' experiences of cognitive impairment following critical illness.

METHODS AND ANALYSIS

The methodology will follow the Joanna Briggs Institute guidelines for scoping reviews. The databases MEDLINE, CINAHL, PsycINFO and Embase will be searched to identify studies appropriate for inclusion. Any peer-reviewed original studies meeting the inclusion criteria and include statements from adult patients about how they experience cognitive impairment following critical illness and ICU admission will be considered. Studies published in English and Scandinavian languages will be included, with no further geographical or cultural limitations. The included studies will be screened by two independent researchers using a standardised data extraction tool and the Mixed Methods Appraisal Tool will be used for critical appraisal. The results will be presented in a tabular form, and data will be supported by narrative descriptions or a narrative summary.

ETHICS AND DISSEMINATION

Since the scoping review methodology aims at synthetising existing research on patients' experiences of cognitive impairment following critical illness, the scoping review does not require ethical approval. The results will be disseminated though a peer-reviewed publication in a scientific journal.

Longitudinal Neurocognitive and Pulmonological Profile of Long COVID-19: Protocol for the COVIMMUNE-Clin Study

Background

There is a dearth of information about “brain fog,” characterized by concentration, word-finding, or memory problems, which has been listed in the new World Health Organization provisional classification “U09.9 Post-COVID-19 Condition.” Moreover, the extent to which these symptoms may be associated with neurological, pulmonary, or psychiatric difficulties is unclear.

Objective

This ongoing cohort study aims to carefully assess neurocognitive function in the context of the neurological, psychiatric, and pulmonary sequelae of SARS-CoV-2 infection among patients with asymptomatic/mild and severe cases of COVID-19 after remission, including actively recruited healthy controls.

Methods

A total of 150 participants will be included in this pilot study. The cohort will comprise patients who tested positive for SARS-CoV-2 infection with either an asymptomatic course or a mild course defined as no symptoms except for olfactory and taste dysfunction (n=50), patients who tested positive for SARS-CoV-2 infection with a severe disease course (n=50), and a healthy control group (n=50) with similar age and sex distribution based on frequency matching. A comprehensive neuropsychological assessment will be performed comprising nuanced aspects of complex attention, including language, executive function, verbal and visual learning, and memory. Psychiatric, personality, social and lifestyle factors, sleep, and fatigue will be evaluated. Brain magnetic resonance imaging, neurological and physical assessment, and pulmonological and lung function examinations (including body plethysmography, diffusion capacity, clinical assessments, and questionnaires) will also be performed. Three visits are planned with comprehensive testing at the baseline and 12-month visits, along with brief neurological and neuropsychological examinations at the 6-month assessment. Blood-based biomarkers of neurodegeneration will be quantified at baseline and 12-month follow-up.

Results

At the time of submission, the study had begun recruitment through telephone and in-person screenings. The first patient was enrolled in the study at the beginning of April 2021. Interim data analysis of baseline information is expected to be complete by December 2021 and study completion is expected at the end of December 2022. Preliminary group comparisons indicate worse word list learning, short- and long-delayed verbal recall, and verbal recognition in both patient cohorts compared with those of the healthy control group, adjusted for age and sex. Initial volumetric comparisons show smaller grey matter, frontal, and temporal brain volumes in both patient groups compared with those of healthy controls. These results are quite robust but are neither final nor placed in the needed context intended at study completion.

Conclusions

To the best of our knowledge, this is the first study to include objective and comprehensive longitudinal analyses of neurocognitive sequelae of COVID-19 in an extreme group comparison stratified by disease severity with healthy controls actively recruited during the pandemic. Results from this study will contribute to the nascent literature on the prolonged effects of COVID-19 on neurocognitive performance via our coassessment of neuroradiological, neurological, pulmonary, psychiatric, and lifestyle factors.

Trial Registration

International Clinical Trials Registry Platform DRKS00023806; https://trialsearch.who.int/Trial2.aspx?TrialID=DRKS00023806

International Registered Report Identifier (IRRID)

DERR1-10.2196/30259

Association of Health Insurance Status with Outcomes of Sepsis in Adult Patients: A Retrospective Cohort Study

(1) Background: Sepsis is a life-threatening disease, and various demographic and socioeconomic factors affect outcomes in sepsis. However, little is known regarding the potential association between health insurance status and outcomes of sepsis in Korea. We evaluated the association of health insurance and clinical outcomes in patients with sepsis. (2) Methods: Prospective cohort data of adult patients with sepsis and septic shock from March 2016 to December 2018 in three hospitals were retrospectively analyzed. We categorized patients into two groups according to their health insurance status: National Health Insurance (NHI) and Medical Aid (MA). The primary end point was in-hospital mortality. The multivariate logistic regression model and propensity score matching were used. (3) Results: Of a total of 2526 eligible patients, 2329 (92.2%) were covered by NHI, and 197 (7.8%) were covered by MA. The MA group had fewer males, more chronic kidney disease, more multiple sources of infection, and more patients with initial lactate > 2 mmol/L. In-hospital, 28-day, and 90-day mortality were not significantly different between the two groups and in-hospital mortality was not different in the subgroup analysis. Furthermore, health insurance status was not independently associated with in-hospital mortality in multivariate analysis and was not associated with survival outcomes in the propensity score-matched cohort. (4) Conclusions: Our propensity score-matched cohort analysis demonstrated that there was no significant difference in in-hospital mortality by health insurance status in patients with sepsis.

Cystatin C regulates the cytotoxicity of infection-induced endothelial-derived β-amyloid

Infection of rat pulmonary microvascular endothelial cells with the bacterium Pseudomonas aeruginosa induces the production and release of cytotoxic oligomeric tau and beta amyloid (Aβ). Here, we characterized these cytotoxic amyloids. Cytotoxic behavior and oligomeric tau were partially resistant to digestion with proteinase K, but cytotoxicity was abolished by various denaturants including phenol, diethylpyrocarbonate (DEPC), and 1,1,1,3,3,3-hexafluoro-2-isopropanol (HFIP). Ultracentrifugation for 8 h at 150 000 g was required to remove cytotoxic activity from the supernatant. Ultracentrifugation, DEPC treatment, and immunodepletion using antibodies against Aβ also demonstrated that cytoprotective protein(s) are released from endothelial cells during P. aeruginosa infection. Mass spectrometry of endothelial cell culture media following P. aeruginosa infection allowed identification of multiple potential secreted modulators of Aβ, including cystatin C, gelsolin, and ApoJ/clusterin. Immunodepletion, co-immunoprecipitation, and ultracentrifugation determined that the cytoprotective factor released during infection of endothelial cells by P. aeruginosa is cystatin C, which appears to be in a complex with Aβ. Cytoprotective cystatin C may provide a novel therapeutic avenue for protection against the long-term consequences of infection with P. aeruginosa.

Could therapeutic diaries support recovery in psychiatric intensive care?

Despite growing literature surrounding the use of patient diaries in intensive care units within general health care and the positive effects these may have on a patient's psychological recovery from such an admission, no studies exist examining the effects of similar patient diaries in psychiatric intensive care units when used with people experiencing an acute exacerbation of psychosis. This article hypothesises the potential positive effects of diaries kept for patients in psychiatric intensive care units. In the development of strategies to help people in psychiatric crisis understand and manage their own distress and psychological trauma, diaries may be helpful for the prevention of further psychological problems and aid recovery post discharge. Research is required to consider the possible effects of therapeutic diaries and the role of the multidisciplinary team in keeping these within psychiatric intensive care settings.

Intervention fidelity in postintensive care follow-up consultations at ten sites in the RAPIT-trial: A mixed-methods evaluation

AIM

The aim of the study was to evaluate intervention fidelity of nurses' delivery of the RAPIT recovery program for postintensive care patients.

BACKGROUND

Interventions addressing patient problems after intensive care lack description of the process of delivery and the evidence of their effectiveness. This is needed to understand how these interventions work.

DESIGN

Multistage intervention framework in a mixed-methods design. Intervention fidelity strategies were assessed for intervention design, training, delivery, receipt, and enactment with quantitative and qualitative methods inspired by the Medical Research Council and the National Institutes of Health Fidelity Framework.

METHODS

Data collection was embedded in a multicenter randomized controlled trial to explore intervention fidelity of a recovery program (December 2012-February 2017). Ten Danish intensive care units participated in the RAPIT-trial including 386 patients and 27 nurses. Quantitative data covered training and delivery. Qualitative data explored design, quality of delivery, receipt, and enactment seen from nurses' and patients' perspectives. Data were analysed statistically and by systematic deductive-inductive thematic analysis.

FINDINGS

A framework for participatory enactment of a complex intervention was developed and demonstrated delivery with high consistent fidelity across sites. Low delivery doses and variations were related to the program, patient, provider nurses and context.

CONCLUSION

Our study provides insight into the process of intervention fidelity of a nurse-led postintensive care recovery program and potentially enables professionals to understand key factors in cross-site implementation. Although we demonstrate consistent delivery and variations suggest that some patients may benefit more than others.

A Web-Based Recovery Program (ICUTogether) for Intensive Care Survivors: Protocol for a Randomized Controlled Trial

Background

Those who experience a critical illness or condition requiring admission to an intensive care unit (ICU) frequently experience physical and psychological complications as a direct result of their critical illness or condition and ICU experience. Complications, if left untreated, can affect the quality of life of survivors and impact health care resources. Explorations of potential interventions to reduce the negative impact of an ICU experience have failed to establish an evidence-based intervention.

Objective

The aim of this study is to evaluate the impact of a Web-based intensive care recovery program on the mental well-being of intensive care survivors and to determine if it is a cost-effective approach.

Methods

In total, 162 patients that survived an ICU experience will be recruited and randomized into 1 of 2 groups. The intervention group will receive access to the Web-based intensive care recovery program, ICUTogether, 2 weeks after discharge (n=81), and the control group will receive usual care (n=81). Mental well-being will be measured using the Hospital Anxiety and Depression Scale, The Impact of Events Scale-Revised and the 5-level 5-dimension EuroQoL at 3 time points (2 weeks, 6 months, and 12 months post discharge). Family support will be measured using the Multidimensional Scale of Perceived Social Support at 3 time points. Analysis will be conducted on an intention-to-treat basis using regression modeling. Covariates will include baseline outcome measures, study allocation (intervention or control), age, gender, length of ICU stay, APACHE III score, level of family support, and hospital readmissions. Participants’ evaluation of the mobile website will be sought at 12 months postdischarge. A cost utility analysis conducted at 12 months from a societal perspective will consider costs incurred by individuals as well as health care providers.

Results

Participant recruitment is currently underway. Recruitment is anticipated to be completed by December 2020.

Conclusions

This study will evaluate a novel intervention in a group of ICU survivors. The findings from this study will inform a larger study and wider debate about an appropriate intervention in this population.

International Registered Report Identifier (IRRID)

PRR1-10.2196/10935

Ultrasonography: New Insights in its Applicability to Explore Muscle Mass and Musculoskeletal Inflammation in Critically ill Patients

Objective: The main aim of the study was to explore muscle mass changes and to investigate musculoskeletal inflammation in critically ill patients.

Methods: A pure observational study that comprised two musculoskeletal analyses was conducted. Ultrasonography was used to determine the inflammatory process and muscle mass modifications. We assessed the presence of musculoskeletal inflammation and muscles area reduction. We recruited 26 patients and we performed both imaging investigations (shoulder and hip joints, biceps brachii and rectus femoris areas) and anthropometric measurements (mid-upper arm circumference).

Results: More than 70% of patients were classified with low muscle mass, over one half of sarcopenic patients being over-weight and 17% being obese. The relationship between the length of stay in intensive care unit, mechanical ventilation and presence of low mid-upper arm circumference, highlighted a significant difference when comparing sarcopenic and non-sarcopenic groups. Musculoskeletal inflammation expressed by step-down lesions, calcifications and osteophytes, is common in these patients. Statistically significant results were obtained when comparing the dimensions of the investigated muscles. Good inter-observer variability in day 3 of assessment for biceps brachii and rectus femoris was noticed.

Conclusions: More than 1/3 of critically ill patients included in the present study was classified with low muscle mass. The length of stay in intensive care unit and the length of mechanical ventilation had an important impact on sarcopenic patients. Musculoskeletal impairment was frequent, reflected by presence of enthesitis lesions in joints and by dynamic reduction of muscle area.

Genetic variation in the glucocorticoid receptor and psychopathology after dexamethasone administration in cardiac surgery patients

The glucocorticoid receptor (GR) agonist dexamethasone is frequently used for its anti-inflammatory properties. We recently showed that a single high-dose of dexamethasone had long-lasting protective effects on the development of psychopathology after cardiac surgery and postoperative intensive care unit stay. In this study, we investigated whether common genetic variation in the hypothalamic-pituitary-adrenal (HPA)-axis would influence the susceptibility for PTSD and depression after dexamethasone administration. Participants (n = 996) of the Dexamethasone for Cardiac Surgery (DECS) randomized clinical trial were followed after receiving a single high intraoperative dose of dexamethasone (1 mg/kg), a GR agonist, or placebo. PTSD and depressive symptoms were assessed up to four years after cardiac surgery. We focused primarily on five common single nucleotide polymorphisms (SNPs) in the glucocorticoid receptor (GR). Secondarily, we comprehensively assessed common genetic variation in the FK506 binding protein (FKBP5) and the mineralocorticoid receptor (MR). The protective effects of dexamethasone on postoperative PTSD symptoms were dependent on the GR polymorphisms rs41423247 (p = .009), rs10052957 (p = .003), and rs6189 (p = .002), but not on rs6195 (p = .025) or rs6198, (p = .026) after Bonferroni correction. No genotype-dependent effects were found for postoperative depressive symptoms. Also, no associations of FKBP5 and MR polymorphisms were found on PTSD and depression outcomes. Protective effects of dexamethasone on PTSD symptoms after cardiac surgery and ICU stay seem to depend on common genetic variation in its target receptor, the GR. These effects indicate that pre-operative genetic screening could potentially help in stratifying patients for their vulnerability for developing PTSD symptoms after surgery.

Objective Nociceptive Assessment in Ventilated ICU Patients: A Feasibility Study Using Pupillometry and the Nociceptive Flexion Reflex

The concept of objective nociceptive assessment and optimal pain management have gained increasing attention. Despite the known negative short- and long-term consequences of unresolved pain or excessive analgosedation, adequate nociceptive monitoring remains challenging in non-communicative, critically ill adults. In the intensive care unit (ICU), routine nociceptive evaluation is carried out by the attending nurse using the Behavior Pain Scale (BPS) in mechanically ventilated patients. This assessment is limited by medication use (e.g., neuromuscular blocking agents) and the inherent subjective character of nociceptive evaluation by third parties. Here, we describe the use of two nociceptive reflex testing devices as tools for objective pain evaluation: the pupillary dilation reflex (PDR) and nociception flexion reflex (NFR). These measurement tools are non-invasive and well tolerated, providing clinicians and researchers with objective information regarding two different nociceptive processing pathways: (1) the pain-related autonomic reactivity and (2) the ascending component of the somatosensory system. The use of PDR and NFR measurements are currently limited to specialized pain clinics and research institutions because of impressions that these are technically demanding or time-consuming procedures, or even because of a lack of knowledge regarding their existence. By focusing on the two abovementioned nociceptive reflex assessments, this study evaluated their feasibility as a physiological pain measurement method in daily practice. Pursuing novel technologies for evaluating the analgesia level in unconscious patients may further improve individual pharmacological treatment and patient related outcome measures. Therefore, future research must include large well-designed clinical trials in a real-life environment.

Supervised exercise rehabilitation in survivors of critical illness: A randomised controlled trial

Objectives

To investigate the impact of a six-week supervised exercise programme on cardiopulmonary fitness, balance, muscle strength and anxiety and depression in patients who have been discharged home from hospital following an intensive care unit length of stay of greater than 48 h. To investigate patients' perceptions of a six-week supervised exercise programme delivered at three months post hospital discharge.

Design

A single centre parallel, randomised controlled trial.

Setting

Outpatient department of a university teaching hospital in the UK.

Participants

Sixty adult survivors of critical illness, at three months post-hospital discharge.

Intervention

A six-week individually prescribed and supervised exercise program, with associated advice to home exercise modification. Twice weekly exercise sessions were individualised to participant's functional status and included cardiopulmonary, balance and strengthening exercises. Follow up at seven weeks, six months and 12 months.

Outcome measures

Six-Minute Walk Test, BERG balance test, grip strength and Hospital Anxiety and Depression Scale. A pre-designed survey was used to explore patient perceptions of the programme.

Results

Sixty participants (n = 30 received allocated programme in both control and treatment groups) were randomised. Loss to follow up resulted in n = 34 participants for intention to treat analysis at 12 months follow up (leaving n = 19 in control group, n = 15 in treatment group). Median participant age at enrolment was 62 years (interquartile range: 49-72), with a median intensive care unit length of stay of nine days (interquartile range: 4-17). No significant differences were found for the Six-Minute Walk Test at any time point (p > 0.05). Anxiety levels and balance were significantly improved in the treatment group at 12 months (p = 0.006 and p = 0.040, respectively).

Conclusions

Further research is needed into appropriate interventions and outcome measures, target patient populations and timing of such intervention post-hospital discharge.

Intensive care survivor-reported symptoms: a longitudinal study of survivors' symptoms

BACKGROUND

There is growing interest in potential long-term outcomes following intensive care, but few researchers have studied the prevalence of multiple symptoms or the association between pain and other symptoms.

AIMS

To investigate the prevalence of anxiety, depression, fatigue, sleep disturbance and post-traumatic stress symptoms (PTSS) among intensive care survivors 3 months and 1 year after being discharged from an intensive care unit (ICU) and to determine whether pain is associated with higher prevalence of these symptoms 3 months and 1 year after ICU stay.

STUDY DESIGN

Exploratory, longitudinal cohort of intensive care survivors from two mixed ICUs in a tertiary referral hospital in Norway.

METHODS

Intensive care survivors completed surveys at 3 months (n = 118) and 1 year (n = 89) after ICU discharge. Clinical Trials: NCT02279212.

RESULTS

Prevalence rates of intensive care survivors' symptoms were pain 58 (49·2%), anxiety/depression 24/118 (20·8%), fatigue 18/118(15·3%), PTSS 15 (12·8%) and sleep disturbance 58/118 (49·2%) at 3 months after ICU discharge (n = 118). Prevalence rates at 1 year (n = 89) changed only slightly to pain 34 (38·2%), anxiety/depression 17 (20·0%), fatigue 12 (13·8%), PTSS 13 (15·1%) and sleep disturbance 40/89 (46·5%). Associations were strong between pain and presence of sleep disturbance, anxiety/depression, PTSS and fatigue.

CONCLUSIONS

Intensive care survivors have multiple symptoms and the prevalence rates of these symptoms remained almost unchanged from 3 months to 1 year after ICU discharge. The presence of pain was associated with high odds for the presence of sleep disturbance, anxiety/depression, PTSS and fatigue, compared to a no-pain group. ICU survivors may benefit from targeted interventions designed to alleviate the symptom burden.

RELEVANCE TO CLINICAL PRACTICE

Knowledge about ICU survivor's prevalence and risk for having multiple symptoms may help health care professionals to give better care, if needed, to the ICU survivors.

Characteristics and Outcomes of Intensive Care Unit Survivors: Experience of a Multidisciplinary Outpatient Clinic in a Teaching Hospital

OBJECTIVES

To describe the experience of an outpatient clinic with the multidisciplinary evaluation of intensive care unit survivors and to analyze their social, psychological, and physical characteristics in a low-income population and a developing country.

METHODS

Retrospective cohort study. Adult survivors from a general intensive care unit were evaluated three months after discharge in a post-intensive care unit outpatient multidisciplinary clinic over a period of 6 years (2008-2014) in a University Hospital in southern Brazil.

RESULTS

A total of 688 out of 1945 intensive care unit survivors received care at the clinic. Of these, 45.2% had psychological disorders (particularly depression), 49.0% had respiratory impairments (abnormal spirometry), and 24.6% had moderate to intense dyspnea during daily life activities. Patients experienced weight loss during hospitalization (mean=11.7%) but good recovery after discharge (mean gain=9.1%), and 94.6% were receiving nutrition orally. One-third of patients showed a reduction of peripheral muscular strength, and 5.7% had moderate to severe tetraparesis or tetraplegia. There was a significant impairment in quality of life (SF-36), particularly in the physical and emotional aspects and in functional capacity. The economic impacts on the affected families, which were mostly low-income families, were considerable. Most patients did not have full access to rehabilitation services, even though half of the families were receiving financial support from the government.

CONCLUSIONS

A significant number of intensive care unit survivors evaluated 3 months after discharge had psychological, respiratory, motor, and socioeconomic problems; these findings highlight that strategies aimed to assist critically ill patients should be extended to the post-hospitalization period and that this problem is particularly important in low-income populations.

MONITOR-IC study, a mixed methods prospective multicentre controlled cohort study assessing 5-year outcomes of ICU survivors and related healthcare costs: a study protocol

INTRODUCTION

Due to advances in critical care medicine, more patients survive their critical illness. However, intensive care unit (ICU) survivors often experience long-term physical, cognitive and mental problems, summarised as post-intensive care syndrome (PICS), impacting their health-related quality of life (HRQoL). In what frequency PICS occurs, and to what extent this influences ICU survivors' HRQoL, is mostly unknown. The aims of this study are therefore to study the: (1) 5-year patient outcomes, (2) predictors for PICS, (3) ratio between HRQoL of ICU survivors and healthcare-related costs, and (4) care and support needs.

METHODS

The MONITOR-IC study is a multicentre prospective controlled cohort study, carried out in ICUs in four Dutch hospitals. Patients will be included between July 2016 and July 2021 and followed for 5 years. We estimated to include 12000 ICU patients. Outcomes are the HRQoL, physical, cognitive and mental symptoms, ICU survivors' care and support needs, healthcare use and related costs. A control cohort of otherwise seriously ill patients will be assembled to compare long-term patient-reported outcomes. We will use a mixed methods design, including questionnaires, medical data from patient records, cost data from health insurance companies and interviews with patients and family members.

ETHICS AND DISSEMINATION

Insights from this study will be used to inform ICU patients and their family members about long-term consequences of ICU care, and to develop prediction and screening instruments to detect patients at risk for PICS. Subsequently, tailored interventions can be developed and implemented to prevent and mitigate long-term consequences. Additionally, insights into the ratio between HRQoL of ICU patients and related healthcare costs during 5 years after ICU admission can be used to discuss the added value of ICU care from a community perspective. The study has been approved by the research ethics committee of the Radboud University Medical Center (2016-2724).

CLINICAL TRIAL REGISTRATION

NCT03246334.

Follow-up after intensive care treatment: a questionnaire survey of intensive care aftercare in Denmark

BACKGROUND

Rehabilitation efforts after treatment in the intensive care unit (ICU) are termed intensive care aftercare. It includes both early in-hospital follow-up after ICU-discharge and late follow-up after hospital discharge. This study aims to investigate the current ICU-aftercare activities in Denmark.

METHODS

We conducted an electronic questionnaire survey, which was distributed by e-mail to the heads of all 31 general ICUs in Denmark. Specialized ICUs were not included. The questionnaire was divided into the following sections: early ICU-aftercare, late ICU-aftercare, future development and demographics.

RESULTS

Thirty-one ICUs were invited to participate. The response rate was 100%. Overall, 26 of 31 ICUs (84%) offered ICU-aftercare, with the following distribution: early ICU-aftercare (58%), late ICU-aftercare (57%) and both (29%). There were no significant associations between hospital size and provision of ICU-aftercare. For early ICU-aftercare, the most common eligibility criteria were based on ICU length of stay (LOS) (44%) and a decision based upon doctors' discretion (22%). Incidence of guidelines for early ICU-aftercare (44%) and checklists at patient contact (35%) were sparse. The most common early ICU-aftercare items were as follows: respiratory care (82%), tracheostomy care (59%) and nutritional care (59%). For late ICU-aftercare, the most common eligibility criterion was LOS (41%). Guidelines (71%), but not checklist at patient contact (35%), were more common. Most frequent late ICU-aftercare interventions were review of ICU-diaries (59%) and patient charts (53%).

CONCLUSION

Eighty-four per cent of Danish ICUs offered ICU-aftercare to their patients. There was an abundant heterogeneity of eligibility criteria and ICU-aftercare interventions.

Incidence and Risk Factors for Intensive Care Unit-related Post-traumatic Stress Disorder in Veterans and Civilians

RATIONALE

The incidence and risk factors of post-traumatic stress disorder (PTSD) related to the intensive care unit (ICU) experience have not been reported in a mixed veteran and civilian cohort.

OBJECTIVES

To describe the incidence and risk factors for ICU-related PTSD in veterans and civilians.

METHODS

This is a prospective, observational, multicenter cohort enrolling adult survivors of critical illness after respiratory failure and/or shock from three Veterans Affairs and one civilian hospital. After classifying those with/without preexisting PTSD (i.e., PTSD before hospitalization), we then assessed all subjects for ICU-related PTSD at 3 and 12 months post hospitalization.

MEASUREMENTS AND MAIN RESULTS

Of 255 survivors, 181 and 160 subjects were assessed for ICU-related PTSD at 3- and 12-month follow-up, respectively. A high probability of ICU-related PTSD was found in up to 10% of patients at either follow-up time point, whether assessed by PTSD Checklist Event-Specific Version (score ≥ 50) or item mapping using the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). In the multivariable regression, preexisting PTSD was independently associated with ICU-related PTSD at both 3 and 12 months (P < 0.001), as was preexisting depression (P < 0.03), but veteran status was not a consistent independent risk factor for ICU-related PTSD (3-month P = 0.01, 12-month P = 0.48).

CONCLUSIONS

This study found around 1 in 10 ICU survivors experienced ICU-related PTSD (i.e., PTSD anchored to their critical illness) in the year after hospitalization. Preexisting PTSD and depression were strongly associated with ICU-related PTSD.

[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.

Trait anxiety mediates the effect of stress exposure on post-traumatic stress disorder and depression risk in cardiac surgery patients

BACKGROUND

Post-traumatic stress disorder (PTSD) and depression are common after cardiac surgery. Lifetime stress exposure and personality traits may influence the development of these psychiatric conditions.

METHODS

Self-reported rates of PTSD and depression and potential determinants (i.e., trait anxiety and stress exposure) were established 1.5 to 4 years after cardiac surgery. Data was available for 1125 out of 1244 (90.4%) participants. Multivariable linear regressions were conducted to investigate mediating and/or moderating effects of trait anxiety on the relationship between stress exposure, and PTSD and depression. Pre-planned subgroup analyses were performed for both sexes.

RESULTS

PTSD and depression symptoms were present in 10.2% and 13.1% of the participants, respectively. Trait anxiety was a full mediator of the association between stress exposure and depression in both the total cohort and female and male subgroups. Moreover, trait anxiety partially mediated the relationship between stress exposure and PTSD in the full cohort and the male subgroup, whereas trait anxiety fully mediated this relationship in female patients. Trait anxiety did not play a moderating role in the total patient sample, nor after stratification on gender.

LIMITATIONS

The unequal distribution of male (78%) and female patients (22%) might limit the generalizability of our findings. Furthermore, risk factors were investigated retrospectively and with variable follow-up time.

CONCLUSIONS

In cardiac surgery patients, trait anxiety was found to be an important mediator of postoperative PTSD and depression. Prospective research is necessary to verify whether these factors are reliable screening measures of individuals' vulnerability for psychopathology development after cardiac surgery.

A Systematic Review of Patient-reported Outcomes in Randomized Controlled Trials of Unplanned General Surgery

Unplanned general surgery represents a major workload and requires comprehensive evaluation with appropriate outcomes. This study aimed to summarize current reporting of patient-reported outcomes (PROs) in randomized clinical trials (RCTs) in unplanned general surgery. A systematic review identified RCTs reporting PROs in the commonest six areas of unplanned general surgery. Details of the PRO measures were examined using the CONSORT extension for PRO reporting in RCTs. Extracted information about each PRO domain included the reporting of baseline PROs, rationale for PRO selection and whether PRO findings were used in conjunction with clinical outcomes to inform treatment recommendations. The internal validity of included studies was assessed using the Cochrane risk of bias tool. 12,519 abstracts were screened and 20 RCTs containing data from 2037 patients included. Included studies used 14 separate PRO measures covering 35 different health domains. A visual analogue assessment of pain was most frequently reported (n = 13). Reporting of baseline PRO data was uncommon (11/35 PRO domains). The rationale for PRO data collection and a PRO-specific hypothesis were provided for 9 (25.7 %) and 5 (14.3 %) domains, respectively. Seventeen RCTs (85.0 %) used the PRO data alongside clinical outcomes to inform treatment recommendations. Of the 116 risk of bias assessments, 77 (66.0 %) were judged as high or unclear. There is a lack of well designed, and conducted RCTs in unplanned general surgery that include PROs. Future work to define relevant PROs and methods for optimal assessment are needed to inform health care decision-making.

The Intensive care unit specialist: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine

The role of the critical care specialist has been unequivocally established in the management of severely ill patients throughout the world. Data show that the presence of a critical care specialist in the intensive care unit (ICU) environment has reduced morbidity and mortality, improved patient safety, and reduced length of stay and costs. However, many ICUs across the world function as "open ICUs," in which patients may be admitted under a primary physician who has not been trained in critical care medicine. Although the concept of the ICU has gained widespread acceptance amongst medical professionals, hospital administrators and the general public; recognition and the need for doctors specializing in intensive care medicine has lagged behind. The curriculum to ensure appropriate training around the world is diverse but should ideally meet some minimum standards. The World Federation of Societies of Intensive and Critical Care Medicine has set up a task force to address issues concerning the training, functions, roles, and responsibilities of an ICU specialist.

Non-sedation versus sedation with a daily wake-up trial in critically ill patients recieving mechanical ventilation - effects on long-term cognitive function: Study protocol for a randomized controlled trial, a substudy of the NONSEDA trial

Background

The effects of non-sedation on cognitive function in critically ill patients on mechanical ventilation are not yet certain. This trial is a substudy of the NONSEDA trial where critically ill patients are randomized to non-sedation or to sedation with a daily wake-up attempt during mechanical ventilation in the intensive care unit (ICU).

The aim of this substudy is to assess the effects of non-sedation versus sedation with a daily wake-up attempt on long-term cognitive function.

Methods

This is an investigator-initiated, randomized, clinical, parallel-group, superiority trial, including 200 patients.

Inclusion criteria will be adult patients who are intubated and on mechanical ventilation with an expected duration of more than 24 hours. Exclusion criteria will be patients who are comatose at admission and patients with conditions requiring therapeutic coma (i.e., severe head trauma, status epilepticus, patients treated with therapeutic hypothermia and patients with severe hypoxia).

The experimental intervention will be non-sedation supplemented with pain management during mechanical ventilation. The control intervention will be sedation with a daily wake-up attempt.

The primary outcome will be cognitive function 3 months after discharge from intensive care.

The secondary outcomes will be the results of seven specific cognitive tests, performed 3 months after discharge from intensive care, and the association between hypoactive and agitated delirium during ICU admission and long-term cognitive function.

Discussion

If non-sedation can improve long-term cognitive function, it could be an approach worth considering for a larger group of critically ill patients.

Trial registration

The study has been approved by the relevant scientific ethics committee and is registered at ClinicalTrials.gov (ID: NCT02035436, registered on 10 January 2014).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1390-5) contains supplementary material, which is available to authorized users.

Impact of socioeconomic status on mortality and unplanned readmission in septic intensive care unit patients

BACKGROUND

Little is known about the potential association between socioeconomic status (SES) and prognosis after sepsis. We analysed how SES impacted mortality and readmission in septic patients treated at the intensive care unit (ICU) of a university hospital.

METHODS

We performed a cohort study including all adult patients admitted to a general tertiary ICU with severe sepsis or septic shock during 2008-2010. Data on SES (educational level, personal income, and cohabitation), comorbidity, readmissions, and mortality were obtained from public registries. We used Cox regression analysis to examine the impact of SES on 30- and 180-day mortality and on first unplanned readmission within 180 days after hospital discharge.

RESULTS

A total of 387 patients were included of whom 111 (29%) died within 30 days after ICU admission, and 55 (20%) died within 180 days after hospital discharge. Adjusted for sex, comorbidity and SAPS II, patients with low income had a substantially greater risk of dying within 30 days of admission compared to those with high income (35.7% vs. 23.3%; adjusted hazard ratio (HR) 1.99; 95% confidence interval (CI) 1.24-3.21), and tended to show higher 180-day mortality (25.0% vs. 15.5%; adjusted HR 1.72; 95% CI 0.86-3.45). Among patients discharged from hospital, 125 (45%) were readmitted within 180 days. Patients with low education and low income showed a tendency towards early readmission.

CONCLUSIONS

Among septic ICU patients, low income was significantly associated with increased 30-day mortality. There was a trend towards earlier readmission among surviving patients with low educational level and personal income.

A qualitative exploration of acute care and psychological distress experiences of ECMO survivors

OBJECTIVES

To explore the acute care experience of extracorporeal membrane oxygenation (ECMO) patients.

BACKGROUND

ECMO is used in life-threatening scenarios of acute lung or heart failure. The patient's experience with ECMO treatment and the psychological distress are unknown.

METHODS

Qualitative analysis of semi-structured interviews with ECMO survivors 12 months after discharge were conducted and thematically analyzed.

RESULTS

Ten participants treated with ECMO for life-threatening acute heart or lung failure were interviewed. Six themes that captured the ICU experience of ECMO patients were identified including; dealing with crisis, critical care, memory, role of significant others and existence today and tomorrow. Deconditioning was the most frequently reported experience. Patchy factual memories contrasted with detailed delirious memories and paranoid ideations.

CONCLUSION

Patients treated with ECMO experienced deconditioning, perceived threats of serious injury or death and delusional episodes with recalls of psychological distress.

Health-Related Quality of Life and Associated Factors in Intensive Care Unit Survivors 6 Months After Discharge

BACKGROUND

Intensive care unit survivors often have diminished health-related quality of life.

OBJECTIVES

To describe health-related quality of life of former intensive care patients and identify associated factors 6 months after hospital discharge.

METHODS

Six months after discharge, 193 patients from an intensive care unit completed the Short Form-36 Health Survey; measures of sleep; Intensive Care Experience Questionnaire; Depression, Anxiety and Stress Scales; and Posttraumatic Stress Disorder Checklist. Norm-based scores were calculated for the Short Form-36. Bivariate associations with Short Form-36 scores were tested by using the Pearson correlation. Multiple linear regression was used to identify independent associations with health-related quality of life.

RESULTS

All scores on the Short Form-36 (physical component summary, 41.8; mental component summary, 48.2) were less than population norms. Bivariate associations with health-related quality of life (P < .05) were scores on the Acute Physiology and Chronic Health Evaluation II, hospital length of stay, awareness of surroundings and frightening experiences, depression, anxiety, stress, posttraumatic symptoms, and sleep quality at 2 and 6 months. In linear regression, scores on the Acute Physiology and Chronic Health Evaluation II, hospital length of stay, and sleep quality at 6 months were independently associated with Short Form-36 physical summary scores (P < .001); depression and stress were independently associated with mental summary scores (P < .001).

CONCLUSION

Sleep, depression, and stress are potential targets for interventions to improve health-related quality of life and improve recovery.

Non-sedation versus sedation with a daily wake-up trial in critically ill patients receiving mechanical ventilation--effects on physical function: study protocol for a randomized controlled trial: a substudy of the NONSEDA trial

Background

Critically ill patients rapidly loose much of their muscle mass and strength. This can be attributed to prolonged admission, prolonged mechanical ventilation and increased mortality, and it can have a negative impact on the degree of independence and quality of life. In the NONSEDA trial we randomize critically ill patients to non-sedation or sedation with a daily wake-up trial during mechanical ventilation in the intensive care unit. It has never been assessed whether non-sedation affects physical function. The aim of this study is to assess the effects of non-sedation versus sedation with a daily wake-up trial on physical function after discharge from intensive care unit.

Methods/Design

Investigator-initiated, randomized, clinical, parallel-group, superiority trial, including 700 patients in total, with a substudy concerning 200 of these patients. Inclusion criteria will be intubated, mechanically ventilated patients with expected duration of mechanical ventilation >24 h. Exclusion criteria will be patients with severe head trauma, coma at admission or status epilepticus, patients treated with therapeutic hypothermia, patients with PaO₂/FiO₂<9 where sedation might be necessary to ensure sufficient oxygenation or placing the patient in a prone position. The experimental intervention will be non-sedation supplemented with pain management during mechanical ventilation. The control intervention will be sedation with a daily wake-up trial. The co-primary outcome will be quality of life regarding physical function (SF-36, physical component) and degree of independence in activities of daily living (Barthel Index), and this will be assessed for all 700 patients participating in the NONSEDA trial. The secondary outcomes, which will be assessed for the subpopulation of 200 NONSEDA patients in the trial site, Kolding, will be 6-min walking distance, handgrip strength, muscle size (ultrasonographic measurement of the rectus femoris muscle cross-sectional area) and biomechanical data on lower extremity function (maximal voluntary contraction, rate of force development and endurance).

Discussion

This study is the first to investigate the effect of no sedation during critical illness on physical function. If an effect is found, it will add important information on how to prevent muscle weakness following critical illness.

Trial registration

The study has been approved by the relevant scientific ethics committee and is registered at ClinicalTrials.gov (ID: NCT02034942, 9 January 2014).

Symptom burden and health-related quality of life among intensive care unit survivors in Argentina: A prospective cohort study

PURPOSE

Our goal was to describe the evolution of selected physical and psychologic symptoms and identify the determinants of health-related quality of life (HRQOL) after intensive care unit (ICU) discharge.

METHODS

The study is a prospective cohort of consecutive adult patients admitted to a mixed ICU in a university-affiliated hospital, mechanically ventilated for more than 48 hours. During ICU stay, epidemiological data and events probably associated to worsening outcomes were recorded. After discharge, patients were interviewed at 1, 3, 6, and 12 months. Health-related quality of life was assessed with EuroQoL Questionnaire-5 Dimensions, which includes the EQ-index and EQ-Visual Analogue Scale.

RESULTS

One hundred twelve patients were followed up, aged 33 [24-49] years, 68% male, 76% previously healthy, and cranial trauma was the main diagnosis. Physical and psychologic symptoms and moderate/severe problems according to the EQ index progressively decreased after discharge, yet were still highly prevalent after 1 year. EQ index improved from 0.22 [0.01-0.69] to 0.52 [0.08-0.81], 0.66 [0.17-0.79], and 0.68 [0.26-0.86] (P < .001, for all vs month 1). EQ-Visual Analogue Scale remained stable, within acceptable values. Independent determinants of EQ-index were time, duration of mechanical ventilation, shock, weakness, and return to study/work.

CONCLUSIONS

Determinants of HRQOL after ICU discharge were both related to late sequelae of critical illness and to some events occurring in the ICU. Notwithstanding the high symptom burden, patients still perceived their HRQOL as good.

Non-sedation versus sedation with a daily wake-up trial in critically ill patients receiving mechanical ventilation (NONSEDA Trial): study protocol for a randomised controlled trial

BACKGROUND

Through many years, the standard care has been to use continuous sedation of critically ill patients during mechanical ventilation. However, preliminary randomised clinical trials indicate that it is beneficial to reduce the sedation level. No randomised trial has been conducted comparing sedation with no sedation, a priori powered to have all-cause mortality as primary outcome.The objective is to assess the benefits and harms of non-sedation versus sedation with a daily wake-up trial in critically ill patients.

METHODS/DESIGN

The non-sedation (NONSEDA) trial is an investigator-initiated, randomised, clinical, parallel-group, multinational trial designed to include 700 patients from at least six ICUs in Denmark, Norway and Sweden.Inclusion criteria are mechanically ventilated patients with expected duration of mechanical ventilation >24 hours.Exclusion criteria are non-intubated patients, patients with severe head trauma, coma at admission or status epilepticus, patients treated with therapeutic hypothermia, patients with PaO2/FiO2 < 9 where sedation might be necessary to ensure sufficient oxygenation or place the patient in prone position.Experimental intervention is non-sedation supplemented with pain management during mechanical ventilation.Control intervention is sedation with a daily wake-up trial.The primary outcome will be all cause mortality at 90 days after randomization. Secondary outcomes will be: days until death throughout the total observation period; coma- and delirium-free days; highest RIFLE score; days until discharge from the intensive care unit (within 28 days); days until the participant is without mechanical ventilation (within 28 days); and proportion of patients with a major cardiovascular outcome. Explorative outcomes will be: all cause mortality at 28 days after randomisation; days until discharge from the intensive care unit; days until the participant is without mechanical ventilation; days until discharge from the hospital; organ failure.Trial size: we will include 700 participants (2 × 350) in order to detect or reject 25% relative risk reduction in mortality with a type I error risk of 5% and a type II error risk of 20% (power at 80%).

DISCUSSION

The trial investigates potential benefits of non-sedation. This might have large impact on the future treatment of mechanically ventilated critically ill patients.

TRIAL REGISTER

ClinicalTrials.gov NCT0196768, 09.01.2014.

Never ending stories: visual diarizing to recreate autobiographical memory of intensive care unit survivors

AIM

The aim of this study was to explore the potential use of visual diarizing to enable intensive care unit (ICU) survivors to create their story of recovery.

BACKGROUND

An ICU experience can have deleterious psychological and physical effects on survivors leading to reductions in quality of life which for some may be of significant duration. Although there has been exploration of many interventions to support recovery in this group, service provision for survivors remains inconsistent and inadequate.

DESIGN AND PARTICIPANTS

A qualitative interpretive biographical exploration of the ICU experience and recovery phase of ICU survivors using visual diarizing as method. This paper is a component of a larger study and presents an analyses of one participant's visual diary in detail.

METHODS

Data collection was twofold. The participant was supplied with visual diary materials at 2 months post-hospital discharge and depicted his story in words and pictures for a 3-month period, after which he was interviewed. The interview enabled the participant and researcher to interpret the visual diary and create a biographical account of his ICU stay and recovery journey.

FINDINGS

The analysis of one participant's visual diary yielded a wealth of information about his recovery trajectory articulated through the images he chose to symbolize his story. The participant confirmed feelings of persecution whilst in ICU and was unprepared for the physical and psychological disability which ensued following his discharge from hospital. However, his story was one of hope for the future and a determination that good would come out of his experience. He considered using the visual diary enhanced his recovery.

CONCLUSIONS

The participant perceived that visual diarizing enhanced his recovery trajectory by enabling him to recreate his story using visual imagery in a prospective diary.

RELEVANCE TO CLINICAL PRACTICE

Prospective visual diarizing with ICU survivors may have potential as an aid to recovery.