Perspectives of survivors, families and researchers on key outcomes for research in acute respiratory failure

Long-term outcomes after treatment of delirium during critical illness with antipsychotics (MIND-USA): a randomised, placebo-controlled, phase 3 trial

BACKGROUND

Delirium is common during critical illness and is associated with long-term cognitive impairment and disability. Antipsychotics are frequently used to treat delirium, but their effects on long-term outcomes are unknown. We aimed to investigate the effects of antipsychotic treatment of delirious, critically ill patients on long-term cognitive, functional, psychological, and quality-of-life outcomes.

METHODS

This prespecified, long-term follow-up to the randomised, double-blind, placebo-controlled phase 3 MIND-USA Study was conducted in 16 hospitals throughout the USA. Adults (aged ≥18 years) who had been admitted to an intensive care unit with respiratory failure or septic or cardiogenic shock were eligible for inclusion in the study if they had delirium. Participants were randomly assigned-using a computer-generated, permuted-block randomisation scheme with stratification by trial site and age-in a 1:1:1 ratio to receive intravenous placebo, haloperidol, or ziprasidone for up to 14 days. Investigators and participants were masked to treatment group assignment. 3 months and 12 months after randomisation, we assessed survivors' cognitive, functional, psychological, quality-of-life, and employment outcomes using validated telephone-administered tests and questionnaires. This trial was registered with ClinicalTrials.gov, NCT01211522, and is complete.

FINDINGS

Between Dec 7, 2011, and Aug 12, 2017, we screened 20 914 individuals, of whom 566 were eligible and consented or had consent provided to participate. Of these 566 patients, 184 were assigned to the placebo group, 192 to the haloperidol group, and 190 to the ziprasidone group. 1-year survival and follow-up rates were similar between groups. Cognitive impairment was common in all three treatment groups, with a third of survivors impaired at both 3-month and 12-month follow-up in all groups. More than half of the surveyed survivors in each group had cognitive or physical limitations (or both) that precluded employment at both 3-month and 12-month follow-up. At both 3 months and 12 months, neither haloperidol (adjusted odds ratio 1·22 [95% CI 0·73-2.04] at 3 months and 1·12 [0·60-2·11] at 12 months) nor ziprasidone (1·07 [0·59-1·96] at 3 months and 0·94 [0·62-1·44] at 12 months) significantly altered cognitive outcomes, as measured by the Telephone Interview for Cognitive Status T score, compared with placebo. We also found no evidence that functional, psychological, quality-of-life, or employment outcomes improved with haloperidol or ziprasidone compared with placebo.

INTERPRETATION

In delirious, critically ill patients, neither haloperidol nor ziprasidone had a significant effect on cognitive, functional, psychological, or quality-of-life outcomes among survivors. Our findings, along with insufficient evidence of short-term benefit and frequent inappropriate continuation of antipsychotics at hospital discharge, indicate that antipsychotics should not be used routinely to treat delirium in critically ill adults.

FUNDING

National Institutes of Health and the US Department of Veterans Affairs.

Survivorship outcomes for critically ill patients in Australia and New Zealand: A scoping review

INTRODUCTION

Impairments after critical illness, termed the post-intensive care syndrome, are an increasing focus of research in Australasia. However, this research is yet to be cohesively synthesised and/or summarised.

OBJECTIVE

The aim of this scoping review was to explore patient outcomes of survivorship research, identify measures, methodologies, and designs, and explore the reported findings in Australasia.

INCLUSION CRITERIA

Studies reporting outcomes for adult survivors of critical illness from Australia and New Zealand in the following domains: physical, functional, psychosocial, cognitive, health-related quality of life (HRQoL), discharge destination, health care use, return to work, and ongoing symptoms/complications of critical illness.

METHODS

The Joanna Briggs Institute scoping review methodology framework was used. A protocol was published on the open science framework, and the search used Ovid MEDLINE, Scopus, ProQuest, and Google databases. Eligible studies were based on reports from Australia and New Zealand published in English between January 2000 and March 2022.

RESULTS

There were 68 studies identified with a wide array of study aims, methodology, and designs. The most common study type was nonexperimental cohort studies (n = 17), followed by studies using secondary analyses of other study types (n = 13). HRQoL was the most common domain of recovery reported. Overall, the identified studies reported that impairments and activity restrictions were associated with reduced HRQoL and reduced functional status was prevalent in survivors of critical illness. About 25% of 6-month survivors reported some form of disability. Usually, by 6 to12 months after critical illness, impairments had improved.

CONCLUSIONS

Reports of long-term outcomes for survivors of critical illness in Australia highlight that impairments and activity limitations are common and are associated with poor HRQoL. There was little New Zealand-specific research related to prevalence, impact, unmet needs, ongoing symptoms, complications from critical illness, and barriers to recovery.

An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline

Background: This document updates previously published Clinical Practice Guidelines for the management of patients with acute respiratory distress syndrome (ARDS), incorporating new evidence addressing the use of corticosteroids, venovenous extracorporeal membrane oxygenation, neuromuscular blocking agents, and positive end-expiratory pressure (PEEP). Methods: We summarized evidence addressing four "PICO questions" (patient, intervention, comparison, and outcome). A multidisciplinary panel with expertise in ARDS used the Grading of Recommendations, Assessment, Development, and Evaluation framework to develop clinical recommendations. Results: We suggest the use of: 1) corticosteroids for patients with ARDS (conditional recommendation, moderate certainty of evidence), 2) venovenous extracorporeal membrane oxygenation in selected patients with severe ARDS (conditional recommendation, low certainty of evidence), 3) neuromuscular blockers in patients with early severe ARDS (conditional recommendation, low certainty of evidence), and 4) higher PEEP without lung recruitment maneuvers as opposed to lower PEEP in patients with moderate to severe ARDS (conditional recommendation, low to moderate certainty), and 5) we recommend against using prolonged lung recruitment maneuvers in patients with moderate to severe ARDS (strong recommendation, moderate certainty). Conclusions: We provide updated evidence-based recommendations for the management of ARDS. Individual patient and illness characteristics should be factored into clinical decision making and implementation of these recommendations while additional evidence is generated from much-needed clinical trials.

Quality of life after acute kidney injury

PURPOSE OF REVIEW

Deciphering the effect of acute kidney injury (AKI) during critical illness on long-term quality of life versus the impact of conditions that brought on critical illness is difficult.

RECENT FINDINGS

Reports on patient-centred outcomes such as health-related quality of life (HRQOL) have provided insight into the long-lasting impact of critical illness complicated by AKI. However, these data stem from observational studies and randomized controlled trials, which have been heterogeneous in their patient population, timing, instruments used for assessment and reporting. Recent studies have corroborated these findings including lack of effect of renal replacement therapy compared to severe AKI on outcomes and worse physical compared to cognitive dysfunction.

SUMMARY

In adults, more deficits in physical than mental health domains are found in survivors of AKI in critical care, whereas memory deficits and learning impairments have been noted in children. Further study is needed to understand and develop interventions that preserve or enhance the quality of life for individual patients who survive AKI following critical illness, across all ages.

Effect of ICU care bundles on long-term patient-relevant outcomes: a scoping review

OBJECTIVE

Care bundles are considered a key tool to improve bedside quality of care in the intensive care unit (ICU). We explored their effect on long-term patient-relevant outcomes.

DESIGN

Systematic literature search and scoping review.

DATA SOURCES

We searched PubMed, Embase, CINAHL, APA PsycInfo, Web of Science, CDSR and CENTRAL for keywords of intensive care, care bundles, patient-relevant outcomes, and follow-up studies.

ELIGIBILITY CRITERIA

Original articles with patients admitted to adult ICUs assessing bundle implementations and measuring long-term (ie, ICU discharge or later) patient-relevant outcomes (ie, mortality, health-related quality of life (HrQoL), post-intensive care syndrome (PICS), care-related outcomes, adverse events, and social health).

DATA EXTRACTION AND SYNTHESIS

After dual, independent, two-stage selection and charting, eligible records were critically appraised and assessed for bundle type, implementation strategies, and effects on long-term patient-relevant outcomes.

RESULTS

Of 2012 records, 38 met inclusion criteria; 55% (n=21) were before-after studies, 21% (n=8) observational cohort studies, 13% (n=5) randomised controlled trials, and 11% (n=4) had other designs. Bundles pertained to sepsis (n=11), neurocognition (n=6), communication (n=4), early rehabilitation (n=3), pharmacological discontinuation (n=3), ventilation (n=2) or combined bundles (n=9). Almost two-thirds of the studies reported on survival (n=24), 45% (n=17) on care-related outcomes (eg, discharge disposition), and 13% (n=5) of studies on HrQoL. Regarding PICS, 24% (n=9) assessed cognition, 13% (n=5) physical health, and 11% (n=4) mental health, up to 1 year after discharge. The effects of bundles on long-term patient-relevant outcomes was inconclusive, except for a positive effect of sepsis bundles on survival. The inconclusive effects may have been due to the high risk of bias in included studies and the variability in implementation strategies, instruments, and follow-up times.

CONCLUSIONS

There is a need to explore the long-term effects of ICU bundles on HrQoL and PICS. Closing this knowledge gap appears vital to determine if there is long-term patient value of ICU bundles.

Calculating Route: Functional Trajectories and Long-Term Outcomes in Survivors of Severe COVID-19

OBJECTIVES

We investigated functional trajectories after severe COVID-19 and estimated their associations with adverse outcomes (falls, rehospitalizations, institutionalization, or death), cognition and post COVID-19 condition within 1-year of hospital discharge.

DESIGN

Prospective cohort study.

SETTING

A large academic medical center in Sao Paulo, Brazil.

PARTICIPANTS

Survivors of COVID-19 admissions to an intensive care unit.

INTERVENTIONS

None.

MEASUREMENTS

We evaluated participants' disability status before hospital admission and three, six, nine, and twelve months after discharge using 15 activities of daily living. During follow-up, cognition and post COVID-19 condition (defined as persistent symptoms with duration ≥2 months) were assessed. A latent class growth analysis was performed to investigate functional trajectories after discharge.

RESULTS

We included 422 participants (median age 63 years, 13.5% were frail before COVID-19). Four distinct functional trajectories could be identified: "minimal disability trajectory" (37.4% of participants), "mild disability trajectory" (37.9%), "moderate disability trajectory" (16.8%), and "severe disability trajectory" (7.8%). Compared with minimal disability trajectory, the odds ratios (95% confidence interval) for 1-year adverse outcomes were 2.28 (1.38-3.76) for minor disability trajectory; 4.21 (2.10-8.42) for moderate disability trajectory; and 4.16 (1.51-11.46) for severe disability trajectory, even after adjustments. The occurrence of post COVID-19 condition was 67.5% and associated with functional trajectories (p=0.004). Cognition was also associated with functional trajectories.

CONCLUSION

Severe COVID-19 survivors can experience diverse functional trajectories, with those presenting higher levels of disability at increased risk for long-term adverse outcomes. Further investigations are essential to confirm our findings and assess the effectiveness of rehabilitation interventions, aiming to improve health outcomes in those who survived severe COVID-19 and other causes of sepsis.

Putting measurement on a diet: development of a core set of indicators for quality improvement in the ICU using a Delphi method

Background

The number and efficacy of indicators used to monitor and improve the quality of care in Intensive Care Units (ICU) is debatable. This study aimed to select a consensus-based core set of indicators for effective quality improvement in the ICU.

Methods

A Delphi study with a panel of intensivists, ICU nurses, and former ICU patients or relatives (n = 34) from general, teaching, and academic hospitals. Panelists completed a questionnaire in which they scored 69 preselected quality indicators on relevance using a nine-point Likert scale. Indicators were categorized using the rated relevance score into: ‘accepted, ‘equivocal’ and ‘excluded’. Questionnaire results were discussed in focus groups to reach consensus on the final set.

Results

Response rates for the questionnaire and focus groups were 100 and 68%, respectively. Consensus was reached on a final set of 17 quality indicators including patient reported outcome measures (PROMs) and patient reported experience measures (PREMs). Other quality indicators relate to the organization and outcome of ICU care, including safety culture, ICU standardized mortality ratio, and the process indicator ‘learning from and improving after serious incidents’.

Conclusions

ICU clinicians and former patients and relatives developed a consensus-based core set of ICU quality indicators that is relatively short but comprehensive and particularly tailored to end-users needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08236-3.

Methodological Rigor and Transparency in Clinical Practice Guidelines for Nutrition Care in Critically Ill Adults: A Systematic Review Using the AGREE II and AGREE-REX Tools

Background: To evaluate the methodological quality of (1) clinical practice guidelines (CPGs) that inform nutrition care in critically ill adults using the AGREE II tool and (2) CPG recommendations for determining energy expenditure using the AGREE-REX tool. Methods: CPGs by a professional society or academic group, intended to guide nutrition care in critically ill adults, that used a systematic literature search and rated the evidence were included. Four databases and grey literature were searched from January 2011 to 19 January 2022. Five investigators assessed the methodological quality of CPGs and recommendations specific to energy expenditure determination. Scaled domain scores were calculated for AGREE II and a scaled total score for AGREE-REX. Data are presented as medians (interquartile range). Results: Eleven CPGs were included. Highest scoring domains for AGREE II were clarity of presentation (82% [76–87%]) and scope and purpose (78% [66–83%]). Lowest scoring domains were applicability (37% [32–42%]) and stakeholder involvement (46% [33–51%]). Eight (73%) CPGs provided recommendations relating to energy expenditure determination; scores were low overall (37% [36–40%]) and across individual domains. Conclusions: Nutrition CPGs for critically ill patients are developed using systematic methods but lack engagement with key stakeholders and guidance to support application. The quality of energy expenditure determination recommendations is low.

Feasibility of Extracting Meaningful Patient Centered Outcomes From the Electronic Health Record Following Critical Illness in the Elderly

Background

Meaningful patient centered outcomes of critical illness such as functional status, cognition and mental health are studied using validated measurement tools that may often be impractical outside the research setting. The Electronic health record (EHR) contains a plethora of information pertaining to these domains. We sought to determine how feasible and reliable it is to assess meaningful patient centered outcomes from the EHR.

Methods

Two independent investigators reviewed EHR of a random sample of ICU patients looking at documented assessments of trajectory of functional status, cognition, and mental health. Cohen's kappa was used to measure agreement between 2 reviewers. Post ICU health in these domains 12 month after admission was compared to pre- ICU health in the 12 months prior to assess qualitatively whether a patient's condition was “better,” “unchanged” or “worse.” Days alive and out of hospital/health care facility was a secondary outcome.

Results

Thirty six of the 41 randomly selected patients (88%) survived critical illness. EHR contained sufficient information to determine the difference in health status before and after critical illness in most survivors (86%). Decline in functional status (36%), cognition (11%), and mental health (11%) following ICU admission was observed compared to premorbid baseline. Agreement between reviewers was excellent (kappa ranging from 0.966 to 1). Eighteen patients (44%) remained home after discharge from hospital and rehabilitation during the 12- month follow up.

Conclusion

We demonstrated the feasibility and reliability of assessing the trajectory of changes in functional status, cognition, and selected mental health outcomes from EHR of critically ill patients. If validated in a larger, representative sample, these outcomes could be used alongside survival in quality improvement studies and pragmatic clinical trials.

Association of COVID-19 Acute Respiratory Distress Syndrome With Symptoms of Posttraumatic Stress Disorder in Family Members After ICU Discharge

IMPORTANCE

Persistent physical and mental disorders are frequent in survivors of COVID-19-related acute respiratory distress syndrome (ARDS). However, data on these disorders among family members are scarce.

OBJECTIVE

To determine the association between patient hospitalization for COVID-19 ARDS vs ARDS from other causes and the risk of posttraumatic stress disorder (PTSD)-related symptoms in family members.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study in 23 intensive care units (ICUs) in France (January 2020 to June 2020 with final follow-up ending in October 2020). ARDS survivors and family members (1 family member per patient) were enrolled.

EXPOSURES

Family members of patients hospitalized for ARDS due to COVID-19 vs ARDS due to other causes.

MAIN OUTCOMES AND MEASURES

The primary outcome was family member symptoms of PTSD at 90 days after ICU discharge, measured by the Impact of Events Scale-Revised (score range, 0 [best] to 88 [worst]; presence of PTSD symptoms defined by score >22). Secondary outcomes were family member symptoms of anxiety and depression at 90 days assessed by the Hospital Anxiety and Depression Scale (score range, 0 [best] to 42 [worst]; presence of anxiety or depression symptoms defined by subscale scores ≥7). Multivariable logistic regression models were used to determine the association between COVID-19 status and outcomes.

RESULTS

Among 602 family members and 307 patients prospectively enrolled, 517 (86%) family members (median [IQR] age, 51 [40-63] years; 72% women; 48% spouses; 26% bereaved because of the study patient's death; 303 [50%] family members of COVID-19 patients) and 273 (89%) patients (median [IQR] age, 61 [50-69] years; 34% women; 181 [59%] with COVID-19) completed the day-90 assessment. Compared with non-COVID-19 ARDS, family members of patients with COVID-19 ARDS had a significantly higher prevalence of symptoms of PTSD (35% [103/293] vs 19% [40/211]; difference, 16% [95% CI, 8%-24%]; P < .001), symptoms of anxiety (41% [121/294] vs 34% [70/207]; difference, 8% [95% CI, 0%-16%]; P= .05), and symptoms of depression (31% [91/291] vs 18% [37/209]; difference, 13% [95% CI, 6%-21%]; P< .001). In multivariable models adjusting for age, sex, and level of social support, COVID-19 ARDS was significantly associated with increased risk of PTSD-related symptoms in family members (odds ratio, 2.05 [95% CI, 1.30 to 3.23]).

CONCLUSIONS AND RELEVANCE

Among family members of patients hospitalized in the ICU with ARDS, COVID-19 disease, as compared with other causes of ARDS, was significantly associated with increased risk of symptoms of PTSD at 90 days after ICU discharge.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04341519.

SPLIT ENZ: Survivorship of Patients post Long Intensive care stay, Exploration/Experience in a New Zealand cohort (A mixed methods study protocol) (Preprint)

Background

Post Intensive Care Syndrome (PICS) was defined by the Society of Critical Care Medicine in 2012 with subsequent international research highlighting poor long-term outcomes; reduced quality of life; and impairments, for survivors of critical illness. To date, there has been no published research on the long-term outcomes of survivors of critical illness in New Zealand.

Objective

The aim of this study is to explore long-term outcomes after critical illness in New Zealand. The primary objectives are to describe and quantify symptoms and disability, explore possible risk factors, and to identify unmet needs in survivors of critical illness.

Methods

This will be a mixed methods study with 2 components. First, a prospective cohort study of approximately 100 participants with critical illness will be followed up at 1, 6, and 12 months after hospital discharge. The primary outcome will be disability assessed using the World Health Organization Disability Assessment Scale 2.0. Secondary outcomes will focus on mental health using the Hospital Anxiety and Depression Scale and the Impact of Events Scale-revised, cognitive function using the Montreal Cognitive Assessment (Montreal Cognitive Assessment–BLIND), and health-related quality of life using the European Quality of Life-Five Dimension-Five Level. The second element of the study will use qualitative grounded theory methods to explore participants experiences of recovery and highlight unmet needs.

Results

This study was approved by the New Zealand Northern A Health and Disability Ethics Committee on August 16, 2021 (21/NTA/107), and has been registered with the Australian New Zealand Clinical Trials Registry on October 5, 2021. SPLIT ENZ is due to start recruitment in early 2022, aiming to enroll 125 patients over 2 years. Data collection is estimated to be completed by 2024-2025 and will be published once all data are available for reporting.

Conclusions

Although international research has identified the prevalence of PICS and the extent of disability in survivors of critical illness, there is no published research in New Zealand. Research in this field is particularly pressing in the context of COVID-19, an illness that may include PICS in its sequelae.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN1262100133588; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382566&showOriginal=true&isReview=true

International Registered Report Identifier (IRRID)

PRR1-10.2196/35936

New Physical, Mental, and Cognitive Problems 1 Year after ICU Admission: A Prospective Multicenter Study

Rationale: Comprehensive studies addressing the incidence of physical, mental, and cognitive problems after ICU admission are lacking. With an increasing number of ICU survivors, an improved understanding of post-ICU problems is necessary. Objectives: To determine the occurrence and cooccurrence of new physical, mental, and cognitive problems among ICU survivors 1 year after ICU admission, their impact on daily functioning, and risk factors associated with 1-year outcomes. Methods: Prospective multicenter cohort study, including ICU patients ⩾16 years of age, admitted for ⩾12 hours between July 2016 and June 2019. Patients, or proxies, rated their health status before and 1 year after ICU admission using questionnaires. Measurements and Main Results: Validated questionnaires were used to measure frailty, fatigue, new physical symptoms, anxiety and depression, post-traumatic stress disorder, cognitive impairment, and quality of life. Of the 4,793 patients included, 2,345 completed the questionnaires both before and 1 year after ICU admission. New physical, mental, and/or cognitive problems 1 year after ICU admission were experienced by 58% of the medical patients, 64% of the urgent surgical patients, and 43% of the elective surgical patients. Urgent surgical patients experienced a significant deterioration in their physical and mental functioning, whereas elective surgical patients experienced a significant improvement. Medical patients experienced an increase in symptoms of depression. A significant decline in cognitive functioning was experienced by all types of patients. Pre-ICU health status was strongly associated with post-ICU health problems. Conclusions: Overall, 50% of ICU survivors suffer from new physical, mental, and/or cognitive problems. An improved insight into the specific health problems of ICU survivors would enable more personalized post-ICU care.

Objective assessment of metabolism and guidance of ICU rehabilitation with cardiopulmonary exercise testing

PURPOSE OF REVIEW

Addressing the reduced quality of life that affects ICU survivors is the most pressing challenge in critical care medicine. In order to meet this challenge, we must translate lessons learnt from assessing and training athletes to the clinical population, utilizing measurable and targeted parameters obtained during cardiopulmonary exercise testing (CPET).

RECENT FINDINGS

Critical illness survivors demonstrate a persistent reduction in their physical and metabolic function. This manifests in reduced aerobic exercise capacity and metabolic inflexibility. CPET-guided targeted metabolic conditioning has proved beneficial in several clinical populations, including those undergoing high-risk surgery, and could be successfully applied to the rehabilitation of ICU survivors.

SUMMARY

CPET shows great promise in the guidance of rehabilitation in functionally limited ICU survivors. Parallels in the physiological response to exercise in athletes and clinical populations with the stress and consequences of critical illness must be investigated and ultimately applied to the burgeoning population of ICU survivors in order to treat the consequences of survival from critical illness.

Cardiopulmonary Exercise Testing in Critically Ill Coronavirus Disease 2019 Survivors: Evidence of a Sustained Exercise Intolerance and Hypermetabolism

Supplemental Digital Content is available in the text.

OBJECTIVES:

To investigate exercise capacity at 3 and 6 months after a prolonged ICU stay.

DESIGN:

Observational monocentric study.

SETTING:

A post-ICU follow-up clinic in a tertiary university hospital in Liège, Belgium.

PATIENTS:

Patients surviving an ICU stay greater than or equal to 7 days for a severe coronavirus disease 2019 pneumonia and attending our post-ICU follow-up clinic.

MEASUREMENTS AND MAIN RESULTS:

Cardiopulmonary and metabolic variables provided by a cardiopulmonary exercise testing on a cycle ergometer were collected at rest, at peak exercise, and during recovery. Fourteen patients (10 males, 59 yr [52–62 yr], all obese with body mass index > 27 kg/m²) were included after a hospital stay of 40 days (35–53 d). At rest, respiratory quotient was abnormally high at both 3 and 6 months (0.9 [0.83–0.96] and 0.94 [0.86–0.97], respectively). Oxygen uptake was also abnormally increased at 3 months (8.24 mL/min/kg [5.38–10.54 mL/min/kg]) but significantly decreased at 6 months (p = 0.013). At 3 months, at the maximum workload (67% [55–89%] of predicted workload), oxygen uptake peaked at 81% (64–104%) of predicted maximum oxygen uptake, with oxygen pulse and heart rate reaching respectively 110% (76–140%) and 71% (64–81%) of predicted maximum values. Ventilatory equivalent for carbon dioxide remains within normal ranges. The 50% decrease in oxygen uptake after maximum effort was delayed, at 130 seconds (115–142 s). Recovery was incomplete with a persistent anaerobic metabolism. At 6 months, no significant improvement was observed, excepting an increase in heart rate reaching 79% (72–95%) (p = 0.008).

CONCLUSIONS:

Prolonged reduced exercise capacity was observed up to 6 months in critically ill coronavirus disease 2019 survivors. This disability did not result from residual pulmonary or cardiac dysfunction but rather from a metabolic disorder characterized by a sustained hypermetabolism and an impaired oxygen utilization.

Return to Work After Coronavirus Disease 2019 Acute Respiratory Distress Syndrome and Intensive Care Admission: Prospective, Case Series at 6 Months From Hospital Discharge

Joblessness is common in survivors from critical care. Our aim was to describe rates of return to work versus unemployment following coronavirus disease 2019 acute respiratory distress syndrome requiring intensive care admission.

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.

Reduced quality of life in ICU survivors - the story behind the numbers: A mixed methods study

PURPOSE

To gain insight into the daily functioning of ICU survivors who reported a reduced quality of life (QoL) one year after ICU admission.

MATERIALS AND METHODS

A two-phase mixed method study design. QoL was assessed using the SF-36 questionnaire before admission and after one year (Phase 1). Participants reporting a reduced QoL were invited for an in-depth interview (Phase 2). Interview data were coded thematically using the PROMIS framework.

RESULTS

Of the 797 participants, 173 (22%) reported a reduced QoL, of which 19 purposively selected patients were interviewed. In line with their questionnaire scores, most participants described their QoL as reduced. They suffered from physical, mental and/or cognitive problems, impacting their daily life, restricting hobbies, work, and social activities. A new balance in life, including relationships, had to be found. Some interviewees experienced no changes in their QoL; they were grateful for being alive, set new life priorities, and were able to accept their life with its limitations.

CONCLUSIONS

Reduction in QoL is due to physical, mental, and cognitive health problems, restricting participants what they want to do. However, QoL was not only affected by the critical illness, but also by factors including independency, comorbidity, and life events. Registration: NCT03246334 (clinical trials.gov).

What outcomes should be evaluated in critically ill patients?

Randomized clinical trials in intensive care prioritize disease-focused outcomes rather than patient-centered outcomes. A paradigm shift considering the evaluation of measures after hospital discharge and measures focused on quality of life and common symptoms, such as pain and dyspnea, could better reflect the wishes of patients and their families. However, barriers related to the systematization of the interpretation of these outcomes, the heterogeneity of measurement instruments and the greater difficulty in performing the studies, to date, seem to hinder this change. In addition, the joint participation of patients, families, researchers, and clinicians in the definition of study outcomes is not yet a reality.

The effect of postintensive care syndrome on the quality of life of intensive care unit survivors: A secondary analysis

BACKGROUND

Despite increasing interest in postintensive care syndrome and the quality of life of intensive care unit survivors, the empirical literature on the relationship between these two variables is limited.

OBJECTIVES

This study aimed to examine whether postintensive care syndrome predicts the quality of life of intensive care unit survivors.

METHODS

We analysed secondary data, which were collected as part of a larger cross-sectional study. The participants were recruited from six health institutions in Korea. The data of 496 survivors who had been admitted to an intensive care unit for at least 48 h during the past year were analysed. They responded to measures of postintensive care syndrome and quality of life.

RESULTS

The participants' mean physical and mental component summary scores (quality of life) were 40.08 ± 8.99 and 40.24 ± 11.19, respectively. Physical impairment (β = -0.48, p < 0.001), unemployment (β = -0.19, p < 0.001), low income (β = -0.11, p = 0.004), older age (β = -0.08, p = 0.039), and cognitive impairment (β = -0.11, p = 0.045) predicted lower physical component summary scores. Mental (β = -0.49, p < 0.001) and cognitive impairment (β = -0.14, p = 0.005) and low income (β = -0.09, p = 0.014) predicted mental component summary scores.

CONCLUSIONS

The participants reported poor physical and mental health-related quality of life. Postintensive care syndrome, unemployment, low income, and older age were the main predictors of poor quality of life. In addition, postintensive care syndrome was a stronger risk factor for poor quality of life than demographic characteristics and intensive care unit treatment factors.

Delirium

Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.

Core outcomes sets for studies evaluating critical illness and patient recovery

PURPOSE OF REVIEW

Given the growing body of critical care clinical research publications, core outcome sets (COSs) are important to help mitigate heterogeneity in outcomes assessed and measurement instruments used, and have potential to reduce research waste. This article provides an update on COS projects in critical care medicine, and related resources and tools for COS developers.

RECENT FINDINGS

We identified 28 unique COS projects, of which 15 have published results as of May 2020. COS topics relevant to critical care medicine include mechanical ventilation, cardiology, stroke, rehabilitation, and long-term outcomes (LTOs) after critical illness. There are four COS projects for coronavirus disease 2019 (COVID-19), with a 'meta-COS' summarizing common outcomes across these projects. To help facilitate COS development, there are existing resources, standards, guidelines, and tools available from the Core Outcome Measures in Effectiveness Trials Initiative (www.comet-initiative.org/) and the National Institutes of Health-funded Improve LTO project (www.improvelto.com/).

SUMMARY

Many COS projects have been completed in critical care, with more on-going COS projects, including foci from across the spectrum of acute critical care, COVID-19, critical care rehabilitation, and patient recovery and LTOs. Extensive resources are accessible to help facilitate rigorous COS development.

Evaluating Covid-19 Injury Claims With a Focus on Workers' Compensation

: COVID-19 illness can cause multiorgan illness. Some States have passed legislation granting a rebuttable presumption of causation by workplace exposure in certain occupations. This paper summarizes methodology for evaluating claimants utilizing known science and as well as information from the American Medical Association Guides resources.

Identifying Clinical Research Priorities in Adult Pulmonary and Critical Care. NHLBI Working Group Report

Preventing, treating, and promoting recovery from critical illness due to pulmonary disease are foundational goals of the critical care community and the NHLBI. Decades of clinical research in acute respiratory distress syndrome, acute respiratory failure, pneumonia, and sepsis have yielded improvements in supportive care, which have translated into improved patient outcomes. Novel therapeutics have largely failed to translate from promising preclinical findings into improved patient outcomes in late-phase clinical trials. Recent advances in personalized medicine, "big data," causal inference using observational data, novel clinical trial designs, preclinical disease modeling, and understanding of recovery from acute illness promise to transform the methods of pulmonary and critical care clinical research. To assess the current state of, research priorities for, and future directions in adult pulmonary and critical care research, the NHLBI assembled a multidisciplinary working group of investigators. This working group identified recommendations for future research, including 1) focusing on understanding the clinical, physiological, and biological underpinnings of heterogeneity in syndromes, diseases, and treatment response with the goal of developing targeted, personalized interventions; 2) optimizing preclinical models by incorporating comorbidities, cointerventions, and organ support; 3) developing and applying novel clinical trial designs; and 4) advancing mechanistic understanding of injury and recovery to develop and test interventions targeted at achieving long-term improvements in the lives of patients and families. Specific areas of research are highlighted as especially promising for making advances in pneumonia, acute hypoxemic respiratory failure, and acute respiratory distress syndrome.

Novel approaches to metabolic assessment and structured exercise to promote recovery in ICU survivors

PURPOSE OF REVIEW

Survivorship or addressing impaired quality of life (QoL) in ICU survivors has been named 'the defining challenge of critical care' for this century to address this challenge; in addition to optimal nutrition, we must learn to employ targeted metabolic/muscle assessment techniques and utilize structured, progressive ICU rehabilitative strategies.

RECENT FINDINGS

Objective measurement tools such as ccardiopulmonary exercise testing (CPET) and muscle-specific ultrasound show great promise to assess/treat post-ICU physical dysfunction. CPET is showing that systemic mitochondrial dysfunction may underlie development and persistence of poor post-ICU functional recovery. Finally, recent data indicate that we are poor at delivering effective, early ICU rehabilitation and that there is limited benefit of currently employed later ICU rehabilitation on ICU-acquired weakness and QoL outcomes.

SUMMARY

The combination of nutrition with effective, early rehabilitation is highly likely to be essential to optimize muscle mass/strength and physical function in ICU survivors. Currently, technologies such as muscle-specific ultrasound and CPET testing show great promise to guide ICU muscle/functional recovery. Further, we must evolve improved ICU-rehabilitation strategies, as current methods are not consistently improving outcomes. In conclusion, we must continue to look to other areas of medicine and to athletes if we hope to ultimately improve 'ICU Survivorship'.

The performance of acute versus antecedent patient characteristics for 1-year mortality prediction during intensive care unit admission: a national cohort study

Background

Multiple factors contribute to mortality after ICU, but it is unclear how the predictive value of these factors changes during ICU admission. We aimed to compare the changing performance over time of the acute illness component, antecedent patient characteristics, and ICU length of stay (LOS) in predicting 1-year mortality.

Methods

In this retrospective observational cohort study, the discriminative value of four generalized mixed-effects models was compared for 1-year and hospital mortality. Among patients with increasing ICU LOS, the models included (a) acute illness factors and antecedent patient characteristics combined, (b) acute component only, (c) antecedent patient characteristics only, and (d) ICU LOS. For each analysis, discrimination was measured by area under the receiver operating characteristics curve (AUC), calculated using the bootstrap method. Statistical significance between the models was assessed using the DeLong method (p value < 0.05).

Results

In 400,248 ICU patients observed, hospital mortality was 11.8% and 1-year mortality 21.8%. At ICU admission, the combined model predicted 1-year mortality with an AUC of 0.84 (95% CI 0.84–0.84). When analyzed separately, the acute component progressively lost predictive power. From an ICU admission of at least 3 days, antecedent characteristics significantly exceeded the predictive value of the acute component for 1-year mortality, AUC 0.68 (95% CI 0.68–0.69) versus 0.67 (95% CI 0.67–0.68) (p value < 0.001). For hospital mortality, antecedent characteristics outperformed the acute component from a LOS of at least 7 days, comprising 7.8% of patients and accounting for 52.4% of all bed days. ICU LOS predicted 1-year mortality with an AUC of 0.52 (95% CI 0.51–0.53) and hospital mortality with an AUC of 0.54 (95% CI 0.53–0.55) for patients with a LOS of at least 7 days.

Conclusions

Comparing the predictive value of factors influencing 1-year mortality for patients with increasing ICU LOS, antecedent patient characteristics are more predictive than the acute component for patients with an ICU LOS of at least 3 days. For hospital mortality, antecedent patient characteristics outperform the acute component for patients with an ICU LOS of at least 7 days. After the first week of ICU admission, LOS itself is not predictive of hospital nor 1-year mortality.

Historic review of long-term outcomes research

PURPOSE OF REVIEW

This review summarizes the results from long-term intensive care outcome research over the past 50 years. Key findings from early studies are reflected in citations of contemporary research.

RECENT FINDINGS

The postintensive care syndrome (PICS) is a multifaceted entity of residual disability and complications burdening survivors of critical illness. Some interventions applied early in the history of outcomes research have now been confirmed as effective in counteracting specific PICS components.

SUMMARY

Interest in patient-centred outcomes has been present since the beginning of modern intensive care. Findings from early long-term studies remain valid even in the face of contemporary large registries that facilitate follow-up of larger cohorts. A further understanding of the mechanisms leading to experienced physical and psychological impairment of PICS will be essential to the design of future intervention trials.

Defining patient-centered recovery after critical illness - A qualitative study

PURPOSE

To explore perspectives of adult critical illness survivors and identify important aspects to care and recovery.

MATERIALS AND METHODS

A descriptive, qualitative study of adult survivors of prolonged critical illness, six-months after Intensive Care Unit (ICU) discharge, using semi-structured interviews and thematic analysis. The study was undertaken in an academic, tertiary, regional hospital in Victoria, Australia.

RESULTS

Thirty-five patients participated in the study. Most were male (69%) with median age 64 years. Admissions were predominantly medical (51%), followed by cardiothoracic (26%) and general surgical (23%). Median ICU and hospital length of stay were 5 and 17 days respectively. Qualitative analysis revealed two key theme categories, recovery status and care experience. Three recovery states were identified based on physical and neuropsychological recovery. Care experiences varied across recovery states, including care encounters, communication, support and impact on family and friends, and use of community health services.

CONCLUSION

Critical illness survivors frame their recovery in terms of recovery status and care experience, reflecting existing qualitative domains of physical health, psychological health, cognitive function, social health and life satisfaction. Theme content varied with recovery status, raising the possibility that modifying care experiences or patient perceptions could change recovery outcomes.

Outcomes of critical illness: what is meaningful?

PURPOSE OF REVIEW

In this review, we will discuss efforts and challenges in understanding and developing meaningful outcomes of critical care research, quality improvement and policy, which are patient-centered and goal concordant, rather than mortality alone. We shall discuss different aspects of what could constitute outcomes of critical illness as meaningful to the patients and other stakeholders, including families and providers.

RECENT FINDINGS

Different outcome pathways after critical illness impact the patients, families and providers in multiple ways. For patients who die, it is important to consider the experience of dying. For the increasing number of survivors of critical illness, challenges of survival have surfaced. The physical, mental and social debility that survivors experience has evolved into the entity called post-ICU syndrome. The importance of prehospital health state trajectory and the need for the outcome of critical care to be aligned with the patients' goals and preferences have been increasingly recognized.

SUMMARY

A theoretical framework is outlined to help understand the impact of critical care interventions on outcomes that are meaningful to patients, families and healthcare providers.

Understanding patient-important outcomes after critical illness: a synthesis of recent qualitative, empirical, and consensus-related studies

Purpose of review

Patients surviving critical illness frequently experience long-lasting morbidities. Consequently, researchers and clinicians are increasingly focused on evaluating and improving survivors’ outcomes after hospital discharge. This review synthesizes recent research aimed at understanding the postdischarge outcomes that patients consider important (i.e., patient-important outcomes) for the purpose of advancing future clinical research in the field.

Recent findings

Across multiple types of studies, patients, family members, researchers, and clinicians have consistently endorsed physical function, cognition, and mental health as important outcomes to evaluate in future research. Aspects of social health, such as return to work and changes in interpersonal relationships, also were noted in some research publications. Informed by these recent studies, an international Delphi consensus process (including patient and caregiver representatives) recommended the following core set of outcomes for use in all studies evaluating acute respiratory failure survivors after hospital discharge: survival, physical function (including muscle/nerve function and pulmonary function), cognition, mental health, health-related quality of life, and pain. The Delphi panel also reached consensus on recommended measurement instruments for some of these core outcomes.

Summary

Recent studies have made major advances in understanding patient-important outcomes to help guide future clinical research aimed at improving ICU survivors’ recovery.

Family Health Conversations create awareness of family functioning

BACKGROUND

The whole family is affected if one family member is critically ill. The Family Health Conversation Intervention may give the family tools that support healthier family functioning.

AIMS AND OBJECTIVES

The aim of this study was to identify which components of family function are affected when families participate in Family Health Conversations.

DESIGN

A secondary analysis was performed of existing qualitative interviews. The Family Health Conversation is an intervention where nurses ask the family reflective questions, and reflection is made possible in three conversation sessions.

METHODS

This study included transcribed data from 13 follow-up interviews from seven families attending Family Health Conversations after three and 12 months. Data were analysed with narrative analysis, focusing on family function.

RESULTS

Three themes were identified. The families' family functioning had been supported with: improved understanding of each other-there was an understanding of being in the same situation but still having totally different experiences; more concern for each other-they talked about their different experiences and felt they had become closer to each other; and a process of working through-they had experienced working through various experiences, standing by and supporting, and then being able to move on.

CONCLUSIONS

The Family Health Conversation Intervention is provided to families, accompanied by nurses. The families in this study gained an awareness of their family function that brought the family closer because of improved understanding of each other and the situation. The families experienced openness, and the family members spoke more freely with each other, which facilitated the progress of working through the experience of critical illness and helped to maintain healthy family functioning.

RELEVANCE TO CLINICAL PRACTICE

It is important to have an overall perspective and to recognize the patient and the family as equally important within the family for awareness of family function.

Determinants of self-reported unacceptable outcome of intensive care treatment 1 year after discharge

PURPOSE

Survivors of critical illness often suffer from reduced health-related quality of life (HRQoL) due to long-term physical, cognitive, and mental health problems, also known as post-intensive care syndrome (PICS). Some intensive care unit (ICU) survivors even consider their state of health unacceptable. The aim of this study was to investigate the determinants of self-reported unacceptable outcome of ICU treatment.

METHODS

Patients who were admitted to the ICU for at least 48 h and survived the first year after discharge completed validated questionnaires on overall HRQoL and the components of PICS and stated whether they considered their current state of health an acceptable outcome of ICU treatment. The effects of overall HRQoL and components of PICS on unacceptable outcome were studied using multiple logistic regression analysis.

RESULTS

Of 1453 patients, 67 (5%) reported their health state an unacceptable outcome of ICU treatment. These patients had a lower score on overall HRQoL (EQ-5D-index value of 0.57 vs. 0.81; p < 0.001), but we could not determine a cutoff value of the EQ-5D-index value that reliably identified unacceptable outcome. In the multivariate analysis, only the hospital anxiety and depression scale was significantly associated with an unacceptable outcome (OR 2.06, 99% CI 1.18-3.61).

CONCLUSIONS

Although there is a strong association between low overall HRQoL and self-reported unacceptable outcome of ICU treatment, patients with low overall HRQoL may still consider their outcome acceptable. The mental component of PICS, but not the physical and cognitive component, is strongly associated with self-reported unacceptable outcome.

Triangulated perspectives on outcomes of pulmonary rehabilitation in patients with COPD: a qualitative study to inform a core outcome set

Introduction:

Pulmonary rehabilitation implies a comprehensive assessment. Although several outcomes are commonly measured, those are selected mainly by health professionals and researchers, with the voice of patients and informal caregivers being minimally captured. Qualitative studies are fundamental to enhance our knowledge on perspectives of different stakeholders involved in pulmonary rehabilitation.

Objective:

This study aimed to explore the views of different stakeholders on outcomes of pulmonary rehabilitation, contributing to one of the stages of a core outcome set for pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD).

Methods:

Semi-structured interviews were conducted with 12 patients with COPD, 11 informal carers and 10 health professionals. Data were analysed with content analysis, followed by thematic analysis to gain deeper understanding of the different perspectives.

Results:

A total of 44 outcomes were identified, being the most reported ‘improving functional performance’ (67%) and ‘reducing and taking control over dyspnoea’ (64%). Five relevant themes across stakeholders were generated: having a healthy mind in a healthy body; I can(’t) do it; feeling fulfilled; knowing more, doing better and avoiding doctors and expenses. Although perspectives were mostly consensual, some outcomes were only valued by health professionals (e.g. pulmonary function) or by patients and informal carers (e.g. quality of sleep).

Conclusion:

Views of the different stakeholders on outcomes of pulmonary rehabilitation were similar although, some specificities existed. Comprehensive assessments are needed to reflect what is valued by the different stakeholders in pulmonary rehabilitation. This study contributed to a future core outcome set in this field.

Measuring Outcomes After Critical Illness

Outcomes after critical illness remain poorly understood. Conceptual models developed by other disciplines can serve as a framework by which to increase knowledge about outcomes after critical illness. This article reviews 3 models to understand the distinct but interrelated content of outcome domains, to review the components of functional status, and to describe how injuries and illnesses relate to disabilities and impairments afterward.

Long-term outcome after the acute respiratory distress syndrome: different from general critical illness?

Purpose of review

To review the current research data on long-term outcome and health-related quality of life in survivors of the acute respiratory distress syndrome (ARDS) and to compare these findings with those from non-ARDS patients surviving critical illness.

Recent findings

Between 6 months and 2 years after discharge from ICU, survivors of ARDS present with substantial impairments of the levels of body function (muscle strength, walking capacity and/or physical activity (physical SF-36 score). In contrast to non-ARDS patients from surgical ICUs, a standardized intensified physical therapy during early course of illness in ARDS patients could not show an improvement of long-term physical function performance. Furthermore, a substantial part of further ARDS patients suffer from depression (26–33%), anxiety (38–44%) or posttraumatic stress disorder (22–24%). In general, the level of functional autonomy and daily life activities was reduced, and in one study, 6 months after ICU-discharge this level was significantly lower in ARDS patients compared with non-ARDS patients. In a recent study, 44% of ARDS survivors were jobless 1 year after critical illness, whereas half of previously employed patients returned to work within 4 months after hospital discharge. General health-related quality of life was significantly reduced compared with a matched population in all studies.

Summary

Surviving ARDS is associated with a long-term substantial reduction in health-related quality of life and such a reduction does not differ from findings in patients surviving other critical illness. In further research, a special attention should be paid to prevention measures of the ‘post intensive care syndrome’ as well as to patient important domains, which might better explain the patient's and families’ demands.