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Rhodes A, Wilson C, Zelenkov D, Adams K, Poyant JO, Han X, Faugno A, Montalvo C. "The Psychiatric Domain of Post-Intensive Care Syndrome: A Review for the Intensivist". J Intensive Care Med 2024:8850666241275582. [PMID: 39169853 DOI: 10.1177/08850666241275582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
Post-intensive care syndrome (PICS) is a clinical syndrome characterized by new or worsening changes in mental health, cognition, or physical function that persist following critical illness. The psychiatric domain of PICS encompasses new or worsened psychiatric burdens following critical illness, including post-traumatic stress disorder (PTSD), depression, and anxiety. Many of the established predisposing and precipitating factors for the psychiatric domain of PICS are commonly found in the setting of critical illness, including mechanical ventilation (MV), exposure to sedating medications, and physical restraint. Importantly, previous psychiatric history is a strong risk factor for the development of the psychiatric domain of PICS and should be considered when screening patients to diagnose psychiatric impairment and interventions. Delirium has been associated with psychiatric symptoms following ICU admission, therefore prevention warrants careful consideration. Dexmedetomidine has been shown to have the lowest risk for development of delirium when compared to other sedatives and has been the only sedative studied in relation to the psychiatric domain of PICS. Nocturnal dexmedetomidine and intensive care unit (ICU) diaries have been associated with decreased psychiatric burden after ICU discharge. Studies evaluating the impact of other intra-ICU practices on the development of the psychiatric domain of PICS, including the ABCDEF bundle, depth of sedation, and daily spontaneous awakening trials, have been limited and inconclusive. The psychiatric domain of PICS is difficult to treat and may be less responsive to multidisciplinary post-discharge programs and targeted interventions than the cognitive and physical domains of PICS. Given the high morbidity associated with the psychiatric domain of PICS, intensivists should familiarize themselves with the risk factors and intra-ICU interventions that can mitigate this important and under-recognized condition.
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Affiliation(s)
- Allison Rhodes
- Tufts Medical Center, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA
| | | | | | - Kathryne Adams
- Tufts Medical Center, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA
| | | | - Xuan Han
- Tufts Medical Center, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA
| | - Anthony Faugno
- Tufts Medical Center, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA
| | - Cristina Montalvo
- Tufts Medical Center, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA
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Taylor J, Wilcox ME. Physical and Cognitive Impairment in Acute Respiratory Failure. Crit Care Clin 2024; 40:429-450. [PMID: 38432704 DOI: 10.1016/j.ccc.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Recent research has brought renewed attention to the multifaceted physical and cognitive dysfunction that accompanies acute respiratory failure (ARF). This state-of-the-art review provides an overview of the evidence landscape encompassing ARF-associated neuromuscular and neurocognitive impairments. Risk factors, mechanisms, assessment tools, rehabilitation strategies, approaches to ventilator liberation, and interventions to minimize post-intensive care syndrome are emphasized. The complex interrelationship between physical disability, cognitive dysfunction, and long-term patient-centered outcomes is explored. This review highlights the need for comprehensive, multidisciplinary approaches to mitigate morbidity and accelerate recovery.
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Affiliation(s)
- Jonathan Taylor
- Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029, USA
| | - Mary Elizabeth Wilcox
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
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Carella F, Aliberti S, Stainer A, Voza A, Blasi F. Long-Term Outcomes in Severe Community-Acquired Pneumonia. Semin Respir Crit Care Med 2024; 45:266-273. [PMID: 38395062 DOI: 10.1055/s-0044-1781426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Community-acquired pneumonia (CAP) is globally one of the major causes of hospitalization and mortality. Severe CAP (sCAP) presents great challenges and need a comprehensive understanding of its long-term outcomes. Cardiovascular events and neurological impairment, due to persistent inflammation and hypoxemia, contribute to long-term outcomes in CAP, including mortality. Very few data are available in the specific population of sCAP. Multiple studies have reported variable 1-year mortality rates for patients with CAP up to 40.7%, with a clear influence by age, comorbidities, and disease severity. In terms of treatment, the potential protective role of macrolides in reducing mortality emphasizes the importance of appropriate empiric antibiotic therapy. This narrative review explores the growing interest in the literature focusing on the long-term implications of sCAP. Improved understanding of long-term outcomes in sCAP can facilitate targeted interventions and enhance posthospitalization care protocols.
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Affiliation(s)
- Francesco Carella
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Anna Stainer
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Antonio Voza
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Emergency Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Francesco Blasi
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Du Z, Liu X, Li Y, Wang L, Tian J, Zhang L, Yang L. Depressive symptoms over time among survivors after critical illness: A systematic review and meta-analysis. Gen Hosp Psychiatry 2024; 87:41-47. [PMID: 38306945 DOI: 10.1016/j.genhosppsych.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/22/2023] [Accepted: 12/22/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE Critical illness survivors frequently experience various degrees of depressive symptoms, which hinder their recovery and return to daily life. However, substantial variability in the prevalence of depressive symptoms has been reported among critical illness survivors. The exact prevalence remains uncertain. METHODS A systematic search was performed in PubMed, Embase, CINAHL, and PsycINFO from inception to August 2023 for observational studies that reported depressive symptoms in adult critical illness survivors. The random-effects model was used to estimate the prevalence of depressive symptoms. Subgroup analysis and meta-regression were conducted to explore potential moderators of heterogeneity. Study quality was evaluated using the Joanna Briggs Institute's tool and the GRADE approach. RESULTS Fifty-two studies with 24,849 participants met the inclusion criteria. Overall prevalence estimate of depressive symptoms was 21.1% (95% CI, 18.3-24.1%). The prevalence of depressive symptoms remains stable over time. Point prevalence estimates were 21.3% (95% CI, 9.9-35.4%), 19.9% (95% CI, 14.6-25.9%), 18.5% (95% CI, 9.6-29.2%), 21.0% (95% CI, 16.8-25.5%), and 22.6% (95% CI, 14.4-31.8%) at <3, 3, 6, 12, and > 12 months after discharge from intensive care unit (ICU), respectively. CONCLUSIONS Depressive symptoms may impact 1 in 5 adult critically ill patients within 1 year or more following ICU discharge. An influx of rehabilitation service demand is expected, and risk stratification to make optimal clinical decisions is essential. More importantly, to propose measures for the prevention and improvement of depressive symptoms in patients after critical care, given the continuous, dynamic management of ICU patients, including ICU stay, transition to general wards, and post-hospital.
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Affiliation(s)
- Zhongyan Du
- School of Nursing and Rehabilitation, Shandong University, Jinan 250000, China
| | - Xiaojun Liu
- School of Nursing and Rehabilitation, Shandong University, Jinan 250000, China
| | - Yuanyuan Li
- Department of Nursing, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250000, China
| | - Lina Wang
- School of Nursing and Rehabilitation, Shandong University, Jinan 250000, China
| | - Jiaqi Tian
- School of Nursing and Rehabilitation, Shandong University, Jinan 250000, China
| | - Ling Zhang
- School of Nursing and Rehabilitation, Shandong University, Jinan 250000, China
| | - Lijuan Yang
- School of Nursing and Rehabilitation, Shandong University, Jinan 250000, China; Department of Nursing, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250000, China.
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Chedid M, Shroff GR, Iqbal O, Adabag S, Karim RM. Temporary-permanent pacemakers are associated with better clinical and safety outcomes compared to balloon-tipped temporary pacemakers. Pacing Clin Electrophysiol 2024; 47:203-210. [PMID: 38240391 DOI: 10.1111/pace.14918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/18/2023] [Accepted: 12/21/2023] [Indexed: 02/15/2024]
Abstract
BACKGROUND Balloon Tipped Temporary Pacemakers (BTTP) are the most used temporary pacemakers; however, they are associated with a risk of dislodgement and thromboembolism. Recently, Temporary Permanent Pacemakers (TPPM) have been increasingly used. Evidence of outcomes with TPPM compared to BTTP remains scarce. METHODS Retrospective, chart review study evaluating all patients who underwent temporary pacemaker placement between 2014 and 2022 (N = 126) in the cardiac catheterization laboratory (CCL) at a level 1 trauma center. Primary outcome of this study is to evaluate the safety profile of TPPM versus BTTP. Secondary objectives include patient ambulation and healthcare utilization in patients with temporary pacemakers. RESULTS Both groups had similar baseline characteristics distribution including gender, race, and age at temporary pacemaker insertion (p > .05). Subclavian vein was the most common site of access for the TPPM cohort (89.0%) versus the femoral vein in the BTTP group (65.1%). Ambulation was only possible in the TPPM group (55.6%, p < .001). Lead dislodgement, venous thromboembolism, local hematoma, and access site infections were less frequently encountered in the TPPM group (OR = 0.23 [95% CI (0.10-0.67), p < .001]). Within the subgroup of patients with TPPM, 36.6% of the patients were monitored outside the ICU setting. There was no significant difference in the pacemaker-related adverse events among patients with TPPM based on their in-hospital setting. CONCLUSION TPPM is associated with a more favorable safety profile compared to BTTP. They are also associated with earlier patient ambulation and reduced healthcare utilization.
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Affiliation(s)
- Maroun Chedid
- Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Gautam R Shroff
- Division of Cardiology, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Division of Cardiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Omer Iqbal
- Division of Cardiology, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Division of Cardiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Selçuk Adabag
- Division of Cardiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Veterans Affairs Medical Center, Division of Cardiology, Minneapolis, Minnesota, USA
| | - Rehan M Karim
- Division of Cardiology, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Division of Cardiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Khan BA, Perkins AJ, Khan SH, Unverzagt FW, Lasiter S, Gao S, Wang S, Zarzaur BL, Rahman O, Eltarras A, Qureshi H, Boustani MA. Mobile Critical Care Recovery Program for Survivors of Acute Respiratory Failure: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2353158. [PMID: 38289602 PMCID: PMC10828910 DOI: 10.1001/jamanetworkopen.2023.53158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/04/2023] [Indexed: 02/01/2024] Open
Abstract
Importance Over 50% of Acute Respiratory Failure (ARF) survivors experience cognitive, physical, and psychological impairments that negatively impact their quality of life (QOL). Objective To evaluate the efficacy of a post-intensive care unit (ICU) program, the Mobile Critical Care Recovery Program (m-CCRP) consisting of a nurse care coordinator supported by an interdisciplinary team, in improving the QOL of ARF survivors. Design, Setting, and Participants This randomized clinical trial with concealed outcome assessments among ARF survivors was conducted from March 1, 2017, to April 30, 2022, with a 12-month follow-up. Patients were admitted to the ICU services of 4 Indiana hospitals (1 community, 1 county, 2 academic), affiliated with the Indiana University School of Medicine. Intervention A 12-month nurse-led collaborative care intervention (m-CCRP) supported by an interdisciplinary group of clinicians (2 intensivists, 1 geriatrician, 1 ICU nurse, and 1 neuropsychologist) was compared with a telephone-based control. The intervention comprised longitudinal symptom monitoring coupled with nurse-delivered care protocols targeting cognition, physical function, personal care, mobility, sleep disturbances, pain, depression, anxiety, agitation or aggression, delusions or hallucinations, stress and physical health, legal and financial needs, and medication adherence. Main Outcomes and Measures The primary outcome was QOL as measured by the 36-item Medical Outcomes Study Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS), with scores on each component ranging from 0-100, and higher scores indicating better health status. Results In an intention-to-treat analysis among 466 ARF survivors (mean [SD] age, 56.1 [14.4] years; 250 [53.6%] female; 233 assigned to each group), the m-CCRP intervention for 12 months did not significantly improve the QOL compared with the control group (estimated difference in change from baseline between m-CCRP and control group: 1.61 [95% CI, -1.06 to 4.29] for SF-36 PCS; -2.50 [95% CI, -5.29 to 0.30] for SF-36 MCS. Compared with the control group, the rates of hospitalization were higher in the m-CCRP group (117 [50.2%] vs 95 [40.8%]; P = .04), whereas the 12-month mortality rates were not statistically significantly lower (24 [10.3%] vs 38 [16.3%]; P = .05). Conclusions and Relevance Findings from this randomized clinical trial indicated that a nurse-led 12-month comprehensive interdisciplinary care intervention did not significantly improve the QOL of ARF survivors after ICU hospitalization. These results suggest that further research is needed to identify specific patient groups who could benefit from tailored post-ICU interventions. Trial Registration ClinicalTrials.gov Identifier: NCT03053245.
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Affiliation(s)
- Babar A. Khan
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Indiana University Center for Aging Research, Indianapolis
- Regenstrief Institute Inc, Indianapolis, Indiana
- Indiana University Center for Health Innovation and Implementation Science, Indiana Clinical and Translational Sciences Institute, Indianapolis
| | - Anthony J. Perkins
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Sikandar Hayat Khan
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Indiana University Center for Aging Research, Indianapolis
- Regenstrief Institute Inc, Indianapolis, Indiana
| | | | - Sue Lasiter
- School of Nursing and Health Sciences, University of Missouri, Kansas City
| | - Sujuan Gao
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Sophia Wang
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis
| | - Ben L. Zarzaur
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Omar Rahman
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Ahmed Eltarras
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Hadi Qureshi
- Indiana University Center for Aging Research, Indianapolis
| | - Malaz A. Boustani
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Indiana University Center for Aging Research, Indianapolis
- Regenstrief Institute Inc, Indianapolis, Indiana
- Indiana University Center for Health Innovation and Implementation Science, Indiana Clinical and Translational Sciences Institute, Indianapolis
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Matsuishi Y, Hoshino H, Enomoto Y, Shimojo N, Ikeda M, Kotani M, Kobayashi S, Kido T, Mathis BJ, Nakamura K, Nakano H, Okubo N, Inoue Y. Verifying the Japanese version of the Healthy Aging Brain Care Monitor self-report tool for evaluating post-intensive care syndrome. Aust Crit Care 2023; 36:989-996. [PMID: 36934045 DOI: 10.1016/j.aucc.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 01/17/2023] [Accepted: 02/03/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Post-intensive care syndrome (PICS) requires the use of multiple assessment tools because it affects multiple domains: Cognitive, Functional, and Behavioural/Psychological. Therefore, this study translated the self-report (SR) version of the Healthy Aging Brain Care Monitor (HABC-M), spanning multiple domains, into Japanese and analysed its reliability and validity in a post-intensive care setting. METHODS Patients aged 20 years or older and admitted to the adult intensive care unit from August 2019 to January 2021 were included and surveyed by questionnaire. The 21-item Dementia Assessment Sheet for the Regional Comprehensive Care System was used to validate cognitive and physical aspects, and the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7, and the Post Traumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders 5th edition were used to validate emotional aspects. Reliability was assessed by Cronbach's alpha, and congruent validity by correlation analysis. Multivariate linear regression models were used to identify potential factors for PICS. RESULTS A total of 104 patients (mean age: 64 ± 14 years) with 3 median mechanical ventilation days (interquartile range: 2-5) were enrolled. The Cognitive domain of the HABC-M SR was highly correlated with memory and disorientation (r = 0.77 for each), while the Functional domain was highly correlated with Instrumental Activities of Daily Living Scale (r = 0.75-0.79). The Behavioural/Psychological domain highly correlated with the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Post Traumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders 5th edition (r = 0.75-0.76). Multivariate analysis revealed longer ICU stays associated with lower Cognitive and Functional (p = 0.03 for each) domains and longer mechanical ventilation days with a lower Behavioural/Psychological domain (p < 0.01). CONCLUSION The translated Japanese HABC-M SR showed high validity for assessment of the Cognitive, Functional, and Behavioural/Psychological domains of PICS. Therefore, we recommend that the Japanese version of the HABC-M SR be routinely used in the assessment of PICS.
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Affiliation(s)
- Yujiro Matsuishi
- Neuroscience Nursing, St. Luke's International University, Tokyo, Japan.
| | - Haruhiko Hoshino
- Adult Health Nursing, Department of Nursing, International University of Health and Welfare, Narita, Japan
| | - Yuki Enomoto
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan; University of Tsukuba Hospital, Department of Pediatrics, Tsukuba, Ibaraki, Japan
| | - Nobutake Shimojo
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Mitsuki Ikeda
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Misaki Kotani
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Shunsuke Kobayashi
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Takahiro Kido
- University of Tsukuba Hospital, Department of Pediatrics, Tsukuba, Ibaraki, Japan
| | - Bryan J Mathis
- Medical English Communication Center, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki, 317-0077, Japan
| | - Hidehiko Nakano
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki, 317-0077, Japan
| | - Nobuko Okubo
- Neuroscience Nursing, St. Luke's International University, Tokyo, Japan
| | - Yoshiaki Inoue
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Proffitt T, Menzies V, Grap MJ, Orr T, Thacker L, Ameringer S. Cognitive Impairment, Physical Impairment, and Psychological Symptoms in Intensive Care Unit Survivors. Am J Crit Care 2023; 32:410-420. [PMID: 37907379 DOI: 10.4037/ajcc2023946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
BACKGROUND Post-intensive care syndrome (PICS) affects 25% to 50% of adults who survive an intensive care unit (ICU) stay. Although the compounding of PICS impairments (cognitive, physical, and psychological) could intensify the syndrome, research on relationships among impairments is limited, particularly in patients with delirium. OBJECTIVES To examine associations among PICS impairments and examine delirium status and its relationship to PICS impairments at ICU discharge and 1 month later. METHODS A descriptive, correlational study of adults who survived an ICU stay. Participants completed measures for depression, anxiety, posttraumatic stress, physical function, functional status, and cognition at ICU discharge and 1 month later. Relationships among PICS impairments were examined with Spearman correlations; differences in impairments by delirium status were assessed with t tests. RESULTS Of 50 enrolled participants, 46 were screened for PICS impairment at ICU discharge and 35 were screened 1 month later. Cognitive impairment was the most common impairment at both time points. A positive correlation was found between cognition and functional status at ICU discharge (ρ = 0.50, P = .001) and 1 month later (ρ = 0.54, P = .001). Cognition and physical functioning were positively correlated 1 month after discharge (ρ = 0.46, P = .006). The group with delirium had significantly lower functional status scores than the group without delirium at ICU discharge (P = .04). CONCLUSIONS The findings suggest a moderate correlation between cognitive and physical impairments. This relationship should be explored further; ICU survivors with undiagnosed cognitive impairment may have delayed physical recovery and greater risk for injury.
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Affiliation(s)
- Tracye Proffitt
- Tracye Proffitt is an assistant professor at Virginia Commonwealth University School of Nursing, Richmond, Virginia
| | - Victoria Menzies
- Victoria Menzies is an associate professor at University of Florida College of Nursing, Gainesville, Florida
| | - Mary Jo Grap
- Mary Jo Grap is a professor emeritus at Virginia Commonwealth University School of Nursing
| | - Tamara Orr
- Tamara Orr is a clinical health psychologist at Virginia Commonwealth University School of Medicine, Richmond
| | - Leroy Thacker
- Leroy Thacker II is an associate professor, Department of Biostatistics, Virginia Commonwealth University School of Medicine
| | - Suzanne Ameringer
- Suzanne Ameringer is a professor and associate dean for academic affairs at Virginia Commonwealth University School of Nursing
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Gu Q, Yang S, Fei D, Lu Y, Yu H. A nomogram for predicting sepsis-associated delirium: a retrospective study in MIMIC III. BMC Med Inform Decis Mak 2023; 23:184. [PMID: 37715189 PMCID: PMC10503010 DOI: 10.1186/s12911-023-02282-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 09/02/2023] [Indexed: 09/17/2023] Open
Abstract
OBJECTIVE To develop a nomogram for predicting the occurrence of sepsis-associated delirium (SAD). MATERIALS AND METHODS Data from a total of 642 patients were retrieved from the Medical Information Mart for Intensive Care (MIMIC III) database to build a prediction model. Multivariate logistic regression was performed to identify independent predictors and establish a nomogram to predict the occurrence of SAD. The performance of the nomogram was assessed in terms of discrimination and calibration by bootstrapping with 1000 resamples. RESULTS Multivariate logistic regression identified 4 independent predictors for patients with SAD, including Sepsis-related Organ Failure Assessment(SOFA) (p = 0.004; OR: 1.131; 95% CI 1.040 to 1.231), mechanical ventilation (P < 0.001; OR: 3.710; 95% CI 2.452 to 5.676), phosphate (P = 0.047; OR: 1.165; 95% CI 1.003 to 1.358), and lactate (P = 0.023; OR: 1.135; 95% CI 1.021 to 1.270) within 24 h of intensive care unit (ICU) admission. The area under the curve (AUC) of the predictive model was 0.742 in the training set and 0.713 in the validation set. The Hosmer - Lemeshow test showed that the model was a good fit (p = 0.471). The calibration curve of the predictive model was close to the ideal curve in both the training and validation sets. The DCA curve also showed that the predictive nomogram was clinically useful. CONCLUSION We constructed a nomogram for the personalized prediction of delirium in sepsis patients, which had satisfactory performance and clinical utility and thus could help clinicians identify patients with SAD in a timely manner, perform early intervention, and improve their neurological outcomes.
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Affiliation(s)
- Qiong Gu
- Department of Emergency Medicine, The First Hospital of Jiaxing/Affiliated Hospital of Jiaxing University, Jiaxing, 314001, China
| | - Shucong Yang
- Department of Emergency Medicine, The First Hospital of Jiaxing/Affiliated Hospital of Jiaxing University, Jiaxing, 314001, China
| | - DanTing Fei
- Department of Emergency Medicine, The First Hospital of Jiaxing/Affiliated Hospital of Jiaxing University, Jiaxing, 314001, China
| | - Yuting Lu
- Department of Emergency Medicine, The First Hospital of Jiaxing/Affiliated Hospital of Jiaxing University, Jiaxing, 314001, China
| | - Huijie Yu
- Department of Emergency Medicine, The First Hospital of Jiaxing/Affiliated Hospital of Jiaxing University, Jiaxing, 314001, China.
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Godoy-González M, Navarra-Ventura G, Gomà G, de Haro C, Espinal C, Fortià C, Ridao N, Miguel Rebanal N, Oliveras-Furriols L, Subirà C, Jodar M, Santos-Pulpón V, Sarlabous L, Fernández R, Ochagavía A, Blanch L, Roca O, López-Aguilar J, Fernández-Gonzalo S. Objective and subjective cognition in survivors of COVID-19 one year after ICU discharge: the role of demographic, clinical, and emotional factors. Crit Care 2023; 27:188. [PMID: 37189173 PMCID: PMC10184095 DOI: 10.1186/s13054-023-04478-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 05/04/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Intensive Care Unit (ICU) COVID-19 survivors may present long-term cognitive and emotional difficulties after hospital discharge. This study aims to characterize the neuropsychological dysfunction of COVID-19 survivors 12 months after ICU discharge, and to study whether the use of a measure of perceived cognitive deficit allows the detection of objective cognitive impairment. We also explore the relationship between demographic, clinical and emotional factors, and both objective and subjective cognitive deficits. METHODS Critically ill COVID-19 survivors from two medical ICUs underwent cognitive and emotional assessment one year after discharge. The perception of cognitive deficit and emotional state was screened through self-rated questionnaires (Perceived Deficits Questionnaire, Hospital Anxiety and Depression Scale and Davidson Trauma Scale), and a comprehensive neuropsychological evaluation was carried out. Demographic and clinical data from ICU admission were collected retrospectively. RESULTS Out of eighty participants included in the final analysis, 31.3% were women, 61.3% received mechanical ventilation and the median age of patients was 60.73 years. Objective cognitive impairment was observed in 30% of COVID-19 survivors. The worst performance was detected in executive functions, processing speed and recognition memory. Almost one in three patients manifested cognitive complaints, and 22.5%, 26.3% and 27.5% reported anxiety, depression and post-traumatic stress disorder (PTSD) symptoms, respectively. No significant differences were found in the perception of cognitive deficit between patients with and without objective cognitive impairment. Gender and PTSD symptomatology were significantly associated with perceived cognitive deficit, and cognitive reserve with objective cognitive impairment. CONCLUSIONS One-third of COVID-19 survivors suffered objective cognitive impairment with a frontal-subcortical dysfunction 12 months after ICU discharge. Emotional disturbances and perceived cognitive deficits were common. Female gender and PTSD symptoms emerged as predictive factors for perceiving worse cognitive performance. Cognitive reserve emerged as a protective factor for objective cognitive functioning. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04422444; June 9, 2021.
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Affiliation(s)
- Marta Godoy-González
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Guillem Navarra-Ventura
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| | - Gemma Gomà
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Candelaria de Haro
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Cristina Espinal
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Cristina Fortià
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Natalia Ridao
- Physical and Rehabilitation Medicine Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Nuria Miguel Rebanal
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Clinical Psychology and Psychobiology Department, Universitat de Barcelona, Barcelona, Spain
| | - Laia Oliveras-Furriols
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Carles Subirà
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Critical Care Department, Althaia Xarxa Assistencial Universitària de Manresa, IRIS Research Institute, Manresa, Spain
| | - Mercè Jodar
- Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Neurology Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III, Madrid, Spain
| | - Verónica Santos-Pulpón
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Leonardo Sarlabous
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Rafael Fernández
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Critical Care Department, Althaia Xarxa Assistencial Universitària de Manresa, IRIS Research Institute, Manresa, Spain
| | - Ana Ochagavía
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Lluís Blanch
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Oriol Roca
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Medicine Department, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Josefina López-Aguilar
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Sol Fernández-Gonzalo
- Critical Care Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III, Madrid, Spain
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11
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Keegan A, Strahley A, Taylor SP, Wilson TM, Shah MD, Williamson J, Palakshappa JA. Older Adults' Perspectives on Screening for Cognitive Impairment Following Critical Illness: Pre-Implementation Qualitative Study. Crit Care Explor 2023; 5:e0920. [PMID: 37197588 PMCID: PMC10184981 DOI: 10.1097/cce.0000000000000920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
Screening for cognitive impairment following ICU discharge is recommended but not part of routine care. We sought to understand older adults' perspectives on screening for cognitive impairment following an ICU admission to inform the design and delivery of a cognitive screening intervention. DESIGN Qualitative study using semi-structured interviews. SUBJECTS Adults 60 years and older within 3 months of discharge from an ICU in an academic health system. INTERVENTIONS Interviews were conducted via telephone, audio recorded and transcribed verbatim. All transcripts were coded in duplicate. Discrepancies were resolved by consensus. Codes were organized into themes and subthemes inductively. MEASUREMENTS AND MAIN RESULTS We completed 22 interviews. The mean age of participants was 71 ± 6 years, 14 (63.6%) were men, 16 (72.7%) were White, and 6 (27.3%) were Black. Thematic analysis was organized around four themes: 1) receptivity to screening, 2) communication preferences, 3) information needs, and 4) provider involvement. Most participants were receptive to cognitive screening; this was influenced by trust in their providers and prior experience with cognitive screening and impairment. Participants preferred simple, direct, compassionate communication. They wanted to understand the screening procedure, the rationale for screening, and expectations for recovery. Participants desired input from their primary care provider to have their cognitive screening results placed in the context of their overall health, because they had a trusted relationship, and for convenience. CONCLUSIONS Participants demonstrated limited understanding of and exposure to cognitive screening but see it as potentially beneficial following an ICU stay. Providers should use simple, straightforward language and place emphasis on expectations. Resources may be needed to assist primary care providers with capacity to provide cognitive screening and interpret results for ICU survivors. Implementation strategies can include educational materials for clinicians and patients on rationale for screening and recovery expectations.
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Affiliation(s)
- Alek Keegan
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Ashley Strahley
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Stephanie P Taylor
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
- Carolinas Medical Center, Atrium Health, Charlotte, NC
| | - Taniya M Wilson
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Meehir D Shah
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Jeff Williamson
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Jessica A Palakshappa
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
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12
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Ramnarain D, Pouwels S, Fernández-Gonzalo S, Navarra-Ventura G, Balanzá-Martínez V. Delirium-related psychiatric and neurocognitive impairment and the association with post-intensive care syndrome-A narrative review. Acta Psychiatr Scand 2023; 147:460-474. [PMID: 36744298 DOI: 10.1111/acps.13534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Delirium is common among patients admitted to the intensive care unit (ICU) and its impact on the neurocognitive and psychiatric state of survivors is of great interest. These new-onset or worsening conditions, together with physical alterations, are called post-intensive care syndrome (PICS). Our aim is to update on the latest screening and follow-up options for psychological and cognitive sequelae of PICS. METHOD This narrative review discusses the occurrence of delirium in ICU settings and the relatively new concept of PICS. Psychiatric and neurocognitive morbidities that may occur in survivors of critical illness following delirium are addressed. Future perspectives for practice and research are discussed. RESULTS There is no "gold standard" for diagnosing delirium in the ICU, but two extensively validated tools, the confusion assessment method for the ICU and the intensive care delirium screening checklist, are often used. PICS complaints are frequent in ICU survivors who have suffered delirium and have been recognized as an important public health and socio-economic problem worldwide. Depression, anxiety, post-traumatic stress disorder, and long-term cognitive impairment are recurrently exhibited. Screening tools for these deficits are discussed, as well as the suggestion of early assessment after discharge and at 3 and 12 months. CONCLUSIONS Delirium is a complex but common phenomenon in the ICU and a risk factor for PICS. Its diagnosis is challenging with potential long-term adverse outcomes, including psychiatric and cognitive difficulties. The implementation of screening and follow-up protocols for PICS sequelae is warranted to ensure early detection and appropriate management.
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Affiliation(s)
- Dharmanand Ramnarain
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of Intensive Care Medicine, Saxenburgh Medical Center, Hardenberg, The Netherlands.,Departmentof Medical and Clinical Psychology, Center of Research on Psychological and Somatic disease (CoRPS), Tilburg University, Tilburg, The Netherlands
| | - Sjaak Pouwels
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of General, Abdominal and Minimally Invasive Surgery, Helios Klinikum, Krefeld, Germany
| | - Sol Fernández-Gonzalo
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.,Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Guillem Navarra-Ventura
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Vicent Balanzá-Martínez
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.,Teaching Unit of Psychiatry and Psychological Medicine, Department of Medicine, University of Valencia, Valencia, Spain
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13
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Long-term neurocognitive outcomes after pediatric intensive care: exploring the role of drug exposure. Pediatr Res 2023:10.1038/s41390-022-02460-7. [PMID: 36694029 DOI: 10.1038/s41390-022-02460-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 11/08/2022] [Accepted: 12/21/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Concerns exist regarding the impact of widely used clinical drugs on brain development. This study investigates long-term neurocognitive functioning in relation to frequently used drug exposure at the Pediatric Intensive Care Unit (PICU). METHODS This study compared children aged 6-12 years with previous PICU admission (age ≤1 year) for bronchiolitis requiring mechanical ventilation (patient group, n = 65) to a demographically comparable control group (n = 76) on a broad range of neurocognitive outcomes. The patient group was selected because bronchiolitis seldom manifests neurologically and is therefore not expected to affect neurocognitive functioning in itself. The relation between exposure to sedatives, analgesics and anesthetics and neurocognitive outcomes was assessed by regression analyses. RESULTS The patient group had lower intelligence than the control group (p < 0.001, d = -0.59) and poorer performance in neurocognitive functions; i.e., speed and attention (p = 0.03, d = -0.41) and verbal memory (p < 0.001, d = -0.60). Exposure to sedatives, analgesics and anesthetics was not related to neurocognitive outcomes. CONCLUSIONS Children with PICU admission for bronchiolitis requiring mechanical ventilation are at risk of adverse neurocognitive outcomes. This study found no evidence for a role of exposure to sedatives, analgesics or anesthetics. Findings underline the importance of long-term follow-up after PICU admission, even in the absence of disease with neurological manifestation. IMPACT Animal studies have indicated that exposing the maturing brain to clinical drugs may cause neurodegeneration. Clinical studies show mixed evidence regarding the association between clinical drugs and neurocognitive outcomes. This study provides evidence for considerably lower neurocognitive functioning among children with a history of PICU admission for bronchiolitis compared to healthy peers. Bronchiolitis seldom manifests neurologically and is therefore not expected to affect neurocognitive functioning in itself. We found no evidence supporting a relation between drug exposure (i.e., sedatives, analgesics and anesthetics) and long-term neurocognitive outcomes. Findings underline the importance of structured follow-up after PICU admission.
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14
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Kyranou M, Cheta C, Pampoulou E. Communicating with mechanically ventilated patients who are awake. A qualitative study on the experience of critical care nurses in Cyprus during the COVID-19 pandemic. PLoS One 2022; 17:e0278195. [PMID: 36454794 PMCID: PMC9714938 DOI: 10.1371/journal.pone.0278195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/12/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Modern protocols for light sedation in combination with the increased number of COVID-19 infected patients hospitalized in Intensive Care Units (ICUs) have increased the number of patients who are mechanically ventilated and awake. Nurses require specific skills to care for this vulnerable group of patients. At the same time, nurses report feeling inadequate and frustrated when they attempt to establish communication with mechanically ventilated, conscious patients. STUDY OBJECTIVES The purpose of this study was to explore the strategies nurses use when taking care of conscious, intubated patients in the intensive care unit and the barriers they encounter in their effort to communicate. METHODS For this study, a qualitative design was employed. Data were collected using in-depth semi-structured interviews with 14 intensive care nurses working at ICUs in four different hospitals of Cyprus. The data were analyzed by applying thematic analysis. RESULTS We identified several strategies of unaided (movements-lips, hands, legs-facial expressions, gestures, touching) and aided forms of communication (pen and paper, boards, tablets, mobiles) used by nurses to communicate with patients. However, barriers to communication were reported by the participating nurses mainly pertaining to patients and nurses' characteristics as well as the ICU environment. The health protocols imposed by the pandemic added more obstacles to the communication between nurses and patients mostly related to the use of protective health equipment. CONCLUSIONS The results of this study point to the difficulties nurses in Cyprus face when trying to communicate with conscious patients during mechanical ventilation. It appears that the lack of nurses' training and of appropriate equipment to facilitate augmentative and alternative communication leave the complex communication needs of critically ill patients unaddressed. However, further research including patients' opinions, after they recover, would bring more clarity on this topic. Our study adds evidence to the communication crisis created by the protective health protocols imposed by the pandemic. As such, it highlights the need to educate nurses in augmentative and alternative ways of communication to address communication with mechanically ventilated, conscious patients during their ICU stay.
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Affiliation(s)
- Maria Kyranou
- Department of Nursing, Cyprus University of Technology, Limassol, Cyprus
- * E-mail:
| | - Chariklia Cheta
- American Medical Center/American Heart Institute, Strovolos, Cyprus
| | - Eliada Pampoulou
- Department of Rehabilitation Sciences, Cyprus University of Technology, Limassol, Cyprus
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15
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George TJ, Sheasby J, Taylor JE, Vaquera KA, Curry MW, Harness‐Brumley CL, Myers DP, Erwin GE, Lilly JC, Michael DiMaio J. Early mobilization in coronavirus-19 patients treated with extracorporeal membrane oxygenation. J Card Surg 2022; 37:4536-4542. [PMID: 36316816 PMCID: PMC9877644 DOI: 10.1111/jocs.17079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 08/14/2022] [Accepted: 09/23/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) pneumonia can be associated with refractory respiratory failure requiring extracorporeal membrane oxygenation(ECMO). Although ECMO has helped many COVID patients, optimal management strategies for these patients remain unknown. METHODS We conducted a retrospective review of all COVID patients requiring ECMO at our hospital. Six months into the pandemic, we changed our management strategy to focus on early mobilization. The early mobilization effort included tracheostomy within 48 h of cannulation, decreasing sedation, and an aggressive physical and occupational therapy program progressing toward early ambulation while on ECMO. The primary outcome measured was survival to discharge. The primary stratification was based on the mobilization strategy. RESULTS From 2020 to 2021, 47 COVID patients have been supported with ECMO at our institution. Five are still in the hospital on ECMO. 39 (83%) were supported with venovenous ECMO while 8 (17%) were supported with venoarterial or a right ventricular assist device type configuration. All 47 (100%) were cannulated at bedside with transesophageal echocardiographic guidance. The average age was 47 ± 9 years; 36(77%) were male; and 20 (43%) were Hispanic. The median duration of support was 22 (11-44) days. Excluding those who remain in the hospital and on support, overall survival to discharge was 24/42 (57%). When stratified by mobilization strategy, early tracheostomy and mobilization were associated with significantly improved survival (74% [17/23] vs. 37% [7/19], p = .02). There were no changes in patient acuity or duration of support throughout the study period. CONCLUSION In conclusion, early tracheostomy, decreased sedation, and aggressive mobilization of COVID-19 ECMO patients is associated with improved survival.
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Affiliation(s)
| | | | | | | | | | | | | | - Gary E. Erwin
- Baylor Scott and WhiteThe Heart HospitalPlanoTexasUSA
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16
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Tejero-Aranguren J, Martin RGDM, Poyatos-Aguilera ME, Morales-Galindo I, Cobos-Vargas A, Colmenero M. Incidence and risk factors for postintensive care syndrome in a cohort of critically ill patients. Rev Bras Ter Intensiva 2022; 34:380-385. [PMID: 36351069 PMCID: PMC9749097 DOI: 10.5935/0103-507x.20220224-en] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/23/2022] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVE To determine the incidence of postintensive care syndrome in a cohort of critically ill patients admitted to the intensive care unit and to identify risk factors related to its development in the physical, cognitive and mental health areas. METHODS This was a prospective observational cohort study developed in the intensive care unit of a university hospital. Patients with intensive care unit stays equal to or longer than one week and the need for mechanical ventilation for more than 3 days, shock or delirium were included in the study. Demographic variables, reasons for admission, diagnoses, sedation, type of mechanical ventilation used, complications and length of stay were recorded. A univariate analysis was performed to identify risk factors related to postintensive care syndrome. The scales used for the assessment of the different spheres were Barthel, Pfeiffer, Hospital Anxiety and Depression Scale and Impact of Event Scale-6. The main variables of interest were postintensive care syndrome incidence overall and by domains. Risk factors were examined in each of the health domains (physical, cognitive and mental health). RESULTS Eighty-seven patients were included. The mean Acute Physiology and Chronic Health Evaluation II score was 16.5. The mean number of intensive care unit days was 17. The incidence of global postintensive care syndrome was 56.3% (n = 49, 95%CI 45.8 - 66.2%). The incidence of postintensive care syndrome in each of the spheres was 32.1% (physical), 11.5% (cognitive), and 36.6% (mental health). CONCLUSIONS The incidence of postintensive care syndrome is 56.3%. The mental health sphere is the most frequently involved. The risk factors are different depending on the area considered.
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Affiliation(s)
- Julia Tejero-Aranguren
- Intensive Care Department, Hospital Universitario Clínico San
Cecilio, POD Medicina Clínica y Salud Pública, Universidad de Granada - Granada,
Spain
| | - Raimundo García-del Moral Martin
- Intensive Care Department, Hospital Universitario Clínico San
Cecilio, POD Medicina Clínica y Salud Pública, Universidad de Granada - Granada,
Spain
| | - Maria Eugenia Poyatos-Aguilera
- Intensive Care Department, Hospital Universitario Clínico San
Cecilio, POD Medicina Clínica y Salud Pública, Universidad de Granada - Granada,
Spain
| | - Ildaura Morales-Galindo
- Intensive Care Department, Hospital Universitario Clínico San
Cecilio, POD Medicina Clínica y Salud Pública, Universidad de Granada - Granada,
Spain
| | - Angel Cobos-Vargas
- Intensive Care Department, Hospital Universitario Clínico San
Cecilio, POD Medicina Clínica y Salud Pública, Universidad de Granada - Granada,
Spain
| | - Manuel Colmenero
- Intensive Care Department, Hospital Universitario Clínico San
Cecilio, POD Medicina Clínica y Salud Pública, Universidad de Granada - Granada,
Spain
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17
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Henao-Castaño ÁM, Rivera-Romero N, Ospina Garzon HP. Experience of Post-ICU Syndrome in Critical Disease Survivors. AQUICHAN 2022. [DOI: 10.5294/aqui.2022.22.1.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction: Surviving Intensive Care Unit (ICU) brings positive and negative feelings, depending on each person’s experience. Likewise, some patients may present with negative mental and physical consequences after discharge, causing a very complex stay at home.
Aim: To understand the experience of critical illness survivors after three months of ICU discharge.
Methods: Hermeneutical phenomenological study using in-depth interviews with 15 adult participants after three months of ICU discharge. Data analysis was made considering Cohen, Kahn, and Steeves’ procedures.
Results: Phenomenological analysis revealed three existential themes: Changes in memory and mood, Changes in day-to-day life, and My body after ICU.
Conclusion: Surviving ICU brings with it positive aspects such as winning a battle against death. However, psychological, emotional, and physical consequences after discharge turn it into an exhausting experience.
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18
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Henao Castaño ÁM, Villamil Buitrago AV, Marín Ramírez S, Cogollo Hernandez CA. Características del síndrome post cuidado intensivo: revisión de alcance. INVESTIGACIÓN EN ENFERMERÍA: IMAGEN Y DESARROLLO 2021. [DOI: 10.11144/javeriana.ie23.csci] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Objetivo: identificar la evidencia disponible de las características del síndrome post unidad de cuidado intensivo en el paciente que egresa de la unidad de cuidado intensivo. Método: revisión de alcance con la metodología del Joanna Briggs Institut, en cinco bases de datos con la estrategia de búsqueda ([PostIntensive AND Care AND Syndrome] [Nursing AND Care AND PICS]). Se incluyeron estudios primarios publicados entre los años 2010 y 2020, disponibles en texto completo. Resultados: después del análisis de los 48 estudios primarios se extrajeron seis categorías temáticas así: aspecto cognitivo en el síndrome post UCI, osteomusculares, psicoemocionales, estrategias de prevención con modelos de sobrevivientes de UCI, síndrome post unidad cuidado intensivo en la familia y herramientas de evaluación. Conclusiones: mejorar la calidad de atención de los pacientes que presentan este síndrome, prevenir la aparición y aumentar la calidad de vida prestada a los sobrevivientes de UCI y sus familias. La evidencia reporta que entre los cuidadores se pueden desencadenar distintos trastornos que disminuyen su calidad de vida. La enfermería juega un papel crucial en la prevención de la aparición del síndrome mediante estrategias en la UCI e interdisciplinares; los planes de egreso y seguimiento a los pacientes pueden lograr que estos se rehabiliten más rápido y eviten discapacidades o secuelas a largo plazo.
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Nordness MF, Hayhurst CJ, Pandharipande P. Current Perspectives on the Assessment and Management of Pain in the Intensive Care Unit. J Pain Res 2021; 14:1733-1744. [PMID: 34163231 PMCID: PMC8214553 DOI: 10.2147/jpr.s256406] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/12/2021] [Indexed: 12/02/2022] Open
Abstract
Critical illness is often painful, both from the underlying source of illness, as well as necessary procedures performed for the monitoring and care of these patients. Pain is often under-recognized in the critically ill, especially among those who cannot self-report, so accurate assessment and management continue to be major consideration in their care. Pain management in the intensive care unit (ICU) is an evolving practice, with a focus on accurate and frequent pain assessment, and targeted pharmacologic and non-pharmacologic treatment methods to maximize analgesia and minimize sedation. In this review, we will evaluate several validated methods of pain assessment in the ICU and present management options. We will review the evidence-based recommendations put forth by the largest critical care societies and several high-quality studies related to both the in-hospital approach to pain, as well as the short- and long-term consequences of untreated pain in ICU patients. We conclude with future directions.
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Affiliation(s)
- Mina F Nordness
- Department of General Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina J Hayhurst
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pratik Pandharipande
- Department of General Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Abstract
Delirium, a form of acute brain dysfunction, is very common in the critically ill adult patient population. Although its pathophysiology is poorly understood, multiple factors associated with delirium have been identified, many of which are coincident with critical illness. To date, no drug or non-drug treatments have been shown to improve outcomes in patients with delirium. Clinical trials have provided a limited understanding of the contributions of multiple triggers and processes of intensive care unit (ICU) acquired delirium, making identification of therapies difficult. Delirium is independently associated with poor long term outcomes, including persistent cognitive impairment. A longer duration of delirium is associated with worse long term cognition after adjustment for age, education, pre-existing cognitive function, severity of illness, and exposure to sedatives. Interestingly, differences in prevalence are seen between ICU survivor populations, with survivors of acute respiratory distress syndrome experiencing higher rates of cognitive impairment at early follow-up compared with mixed ICU survivor populations. Although cognitive performance improves over time for some ICU survivors, impairment is persistent in others. Studies have so far been unable to identify patients at higher risk of long term cognitive impairment; this is an active area of scientific investigation.
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Affiliation(s)
- M Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Timothy D Girard
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
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21
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Abstract
OBJECTIVES Critical illness can cause severe cognitive impairments. The objective of this trial was to assess the effect of nonsedation versus sedation with a daily wake-up call during mechanical ventilation on cognitive function in adult survivors of critical illness. DESIGN Single-center substudy of the multicenter, randomized Non-sedation Versus Sedation With a Daily Wake-up Trial in Critically Ill Patients Receiving Mechanical Ventilation trial. Three months after ICU-discharge participants were tested for cognitive function by a neuropsychologist. SETTING Mixed 14-bed ICU in teaching hospital. PATIENTS A total of 205 critically ill, orally intubated, and mechanically ventilated adults. INTERVENTIONS Patients were randomized within the first 24 hours from intubation to either nonsedation with sufficient analgesia or light sedation with a daily wake-up call during mechanical ventilation. MEASUREMENTS AND MAIN RESULTS A total of 118 patients survived to follow-up and 89 participated (75%). The participating survivors in the two groups did not differ regarding baseline data or premorbid cognitive impairments. Sedated patients had received more sedatives, whereas doses of morphine and antipsychotics were equal. The primary outcome was that no significant difference was found in the number of patients with mild/moderate cognitive impairments (six nonsedated patients vs four sedated patients) or severe cognitive impairments (16 nonsedated patients vs 17 sedated patients; p = 0.71). Secondary outcomes were cognitive test scores, and no differences were found between the scores in nonsedated and sedated patients. Hypothetical worst case scenarios where all patients, who had not participated in follow-up assessment, were assumed to have severe cognitive impairments were analyzed, but still no difference between the groups was found. We found more patients with delirium in the sedated group (96% vs 69% of patients; p = 0.002) and increased duration of delirium in sedated patients (median 5 vs 1 d; p < 0.001). Delirium subtypes were equally distributed between the groups, with hypoactive delirium most frequent (61%), followed by mixed delirium (39%). CONCLUSIONS Nonsedation did not affect cognitive function 3 months after ICU-discharge.
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Cyr S, Guo DX, Marcil MJ, Dupont P, Jobidon L, Benrimoh D, Guertin MC, Brouillette J. Posttraumatic stress disorder prevalence in medical populations: A systematic review and meta-analysis. Gen Hosp Psychiatry 2021; 69:81-93. [PMID: 33582645 DOI: 10.1016/j.genhosppsych.2021.01.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/19/2021] [Accepted: 01/19/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE PTSD is increasingly recognized following medical traumas although is highly heterogeneous. It is difficult to judge which medical contexts have the most traumatic potential and where to concentrate further research and clinical attention for prevention, early detection and treatment. The objective of this study was to compare PTSD prevalence in different medical populations. METHODS A systematic review of the literature on PTSD following medical traumas was conducted as well as a meta-analysis with final pooled result and 95% confidence intervals presented. A meta-regression was used to investigate the impact of potential effect modifiers (PTSD severity, age, sex, timeline) on study effect size between prevalence studies. RESULTS From 3278 abstracts, the authors extracted 292 studies reporting prevalence. Using clinician-administered reports, the highest 24 month or longer PTSD prevalence was found for intraoperative awareness (18.5% [95% CI=5.1%-36.6%]) and the lowest was found for epilepsy (4.5% [95% CI=0.2%-12.6%]). In the overall effect of the meta-regression, only medical events or procedures emerged as significant (p = 0.006) CONCLUSION: This review provides clinicians with greater awareness of medical contexts most associated with PTSD, which may assist them in the decision to engage in more frequent, earlier screening and referral to mental health services.
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Affiliation(s)
- Samuel Cyr
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada; Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - De Xuan Guo
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Marie-Joëlle Marcil
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada; Department of Psychiatry and Addiction, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Patrice Dupont
- Health Sciences Library, Université de Montréal, Montreal, Quebec, Canada
| | - Laurence Jobidon
- Department of Psychiatry and Addiction, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - David Benrimoh
- Department of Psychiatry, McGill University, Montreal, Canada
| | - Marie-Claude Guertin
- Montreal Health Innovations Coordinating Center, Montreal, Montreal, Quebec, Canada
| | - Judith Brouillette
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada; Department of Psychiatry and Addiction, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.
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23
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Abstract
PURPOSES OF REVIEW Critically ill patients frequently require mechanical ventilation as part of their care. Administration of analgesia and sedation to ensure patient comfort and facilitate mechanical ventilation must be balanced against the known negative consequences of excessive sedation. The present review focuses on the current evidence for sedation management during mechanical ventilation, including choice of sedatives, sedation strategies, and special considerations for acute respiratory distress syndrome (ARDS). RECENT FINDINGS The Society of Critical Care Medicine recently published their updated clinical practice guidelines for analgesia, agitation, sedation, delirium, immobility, and sleep in adult patients in the ICU. Deep sedation, especially early in the course of mechanical ventilation, is associated with prolonged time to liberation from mechanical ventilation, longer ICU stays, longer hospital stays, and increased mortality. Dexmedetomidine may prevent ICU delirium when administered nocturnally at low doses; however, it was not shown to improve mortality when used as the primary sedative early in the course of mechanical ventilation, though the majority of patients in the informing study failed to achieve the prescribed light level of sedation. In a follow up to the ACURASYS trial, deep sedation with neuromuscular blockade did not result in improved mortality compared to light sedation in patients with severe ARDS. SUMMARY Light sedation should be targeted early in the course of mechanical ventilation utilizing daily interruptions of sedation and/or nursing protocol-based algorithms, even in severe ARDS.
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Shao S, Kang H, Tong Z. Early neuromuscular blocking agents for adults with acute respiratory distress syndrome: a systematic review, meta-analysis and meta-regression. BMJ Open 2020; 10:e037737. [PMID: 33444180 PMCID: PMC7678372 DOI: 10.1136/bmjopen-2020-037737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine whether neuromuscular blocking agents (NMBAs) can decrease the mortality of patients with acute respiratory distress syndrome (ARDS) and improve their clinical outcomes. DESIGN Systematic review, meta-analysis and meta-regression. DATA SOURCES PubMed, Embase, Cochrane Library, Web of Science and ClinicalTrials.gov. METHODS Randomised controlled trials (RCTs) comparing the treatment effect of NMBAs with that of placebo (or traditional treatment) in patients with ARDS were carefully selected. The primary outcome was 90-day mortality. The secondary outcomes were 21-28 days mortality, NMBA-related complications (barotrauma, pneumothorax and intensive care unit (ICU)-acquired muscle weakness), days free of ventilation and days not in the ICU by day 28, Medical Research Council score, Acute Physiology and Chronic Health Evaluation II score and arterial oxygen tension (PaO2)/fractional inspired oxygen (FiO2) (at 48 hours and 72 hours). Random-effects meta-regression was used to explore models involving potential moderators. Trial sequential analysis was performed to estimate the cumulative effect on mortality across RCTs. RESULTS NMBAs were not associated with reduced 90-day mortality (risk ratio (RR) 0.85; 95% CI 0.66 to 1.09; p=0.20). However, they decreased the 21-28 days mortality (RR 0.71; 95% CI 0.53 to 0.96; p=0.02) and the rates of pneumothorax (RR 0.46; 95% CI 0.28 to 0.77; p=0.003) and barotrauma (RR 0.56; 95% CI 0.37 to 0.86; p=0.008). In addition, NMBAs increased PaO2/FiO2 at 48 hours (mean difference (MD) 18.91; 95% CI 4.29 to 33.53; p=0.01) and 72 hours (MD 12.27; 95% CI 4.65 to 19.89; p=0.002). Meta-regression revealed an association between sample size (p=0.042) and short-term mortality. Publication year (p=0.050), sedation strategy (p=0.047) and sample size (p=0.046) were independently associated with PaO2/FiO2 at 48 hours. CONCLUSIONS In summary, the results suggested that use of NMBAs might reduce 21-28 days mortality, NMBA-related complications and oxygenation. However, NMBAs did not reduce the 90-day mortality of patients with ARDS, which contradicts a previous meta-analysis. PROSPERO REGISTRATION NUMBER CRD42019139440.
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Affiliation(s)
- Shuai Shao
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hanyujie Kang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhaohui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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Fernández-Gonzalo S, Navarra-Ventura G, Bacardit N, Gomà Fernández G, de Haro C, Subirà C, López-Aguilar J, Magrans R, Sarlabous L, Aquino Esperanza J, Jodar M, Rué M, Ochagavía A, Palao DJ, Fernández R, Blanch L. Cognitive phenotypes 1 month after ICU discharge in mechanically ventilated patients: a prospective observational cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:618. [PMID: 33087171 PMCID: PMC7579874 DOI: 10.1186/s13054-020-03334-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 10/06/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND ICU patients undergoing invasive mechanical ventilation experience cognitive decline associated with their critical illness and its management. The early detection of different cognitive phenotypes might reveal the involvement of diverse pathophysiological mechanisms and help to clarify the role of the precipitating and predisposing factors. Our main objective is to identify cognitive phenotypes in critically ill survivors 1 month after ICU discharge using an unsupervised machine learning method, and to contrast them with the classical approach of cognitive impairment assessment. For descriptive purposes, precipitating and predisposing factors for cognitive impairment were explored. METHODS A total of 156 mechanically ventilated critically ill patients from two medical/surgical ICUs were prospectively studied. Patients with previous cognitive impairment, neurological or psychiatric diagnosis were excluded. Clinical variables were registered during ICU stay, and 100 patients were cognitively assessed 1 month after ICU discharge. The unsupervised machine learning K-means clustering algorithm was applied to detect cognitive phenotypes. Exploratory analyses were used to study precipitating and predisposing factors for cognitive impairment. RESULTS K-means testing identified three clusters (K) of patients with different cognitive phenotypes: K1 (n = 13), severe cognitive impairment in speed of processing (92%) and executive function (85%); K2 (n = 33), moderate-to-severe deficits in learning-memory (55%), memory retrieval (67%), speed of processing (36.4%) and executive function (33.3%); and K3 (n = 46), normal cognitive profile in 89% of patients. Using the classical approach, moderate-to-severe cognitive decline was recorded in 47% of patients, while the K-means method accurately classified 85.9%. The descriptive analysis showed significant differences in days (p = 0.016) and doses (p = 0.039) with opioid treatment in K1 vs. K2 and K3. In K2, there were more women, patients were older and had more comorbidities (p = 0.001) than in K1 or K3. Cognitive reserve was significantly (p = 0.001) higher in K3 than in K1 or K2. CONCLUSION One month after ICU discharge, three groups of patients with different cognitive phenotypes were identified through an unsupervised machine learning method. This novel approach improved the classical classification of cognitive impairment in ICU survivors. In the exploratory analysis, gender, age and the level of cognitive reserve emerged as relevant predisposing factors for cognitive impairment in ICU patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier:NCT02390024; March 17,2015.
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Affiliation(s)
- Sol Fernández-Gonzalo
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain. .,Centro de Investigación Biomédica En Red en Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain. .,Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain.
| | - Guillem Navarra-Ventura
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Neus Bacardit
- Mental Health Department, Fundació Althaia - Xarxa Assistencial I Universitaria, Manresa, Spain
| | - Gemma Gomà Fernández
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain
| | - Candelaria de Haro
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Carles Subirà
- Critical Care Center, Fundació Althai, Universitat Internacional de Catalunya, Manresa, Spain
| | - Josefina López-Aguilar
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Leonardo Sarlabous
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain
| | - Jose Aquino Esperanza
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Department of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Mercè Jodar
- Centro de Investigación Biomédica En Red en Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.,Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain.,Neurology Department, Parc Taulí Hospital Universitari, I3PT, UAB, Sabadell, Spain
| | - Montse Rué
- Departament of Basic Medical Sciences, Universitat de Lleida, Lleida, Spain.,Health Services Research Network in Chronic Diseases (REDISSEC), Barcelona, Spain
| | - Ana Ochagavía
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Diego J Palao
- Centro de Investigación Biomédica En Red en Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.,Mental Health Department, Parc Taulí Hospital Universitari, I3PT, UAB, Sabadel, Spain.,Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Rafael Fernández
- Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Critical Care Center, Fundació Althai, Universitat Internacional de Catalunya, Manresa, Spain
| | - Lluís Blanch
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Department of Medicine, Universitat de Barcelona, Barcelona, Spain
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Wagner MK, Berg SK, Hassager C, Armand S, Møller JE, Ekholm O, Rasmussen TB, Fisher PM, Knudsen GM, Stenbæk DS. Cognitive impairment and psychopathology in out-of-hospital cardiac arrest survivors in Denmark: The REVIVAL cohort study protocol. BMJ Open 2020; 10:e038633. [PMID: 32994252 PMCID: PMC7526293 DOI: 10.1136/bmjopen-2020-038633] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Cognitive impairment and psychopathology caused by brain hypoxia and the traumatic impact of critical illness are common in cardiac arrest survivors and can lead to negative consequences of everyday life functioning, and further impact mental health in relatives. Most studies have dealt with the mere survival rate after cardiac arrest and not with long-term consequences to mental health in cardiac arrest survivors. Importantly, we face a gap in our knowledge about suitable screening tools in the early post-arrest phase for long-term risk prediction of mental health problems. This study aims to evaluate the efficacy of a novel screening procedure to predict risk of disabling cognitive impairment and psychopathology 3 months after cardiac arrest. Furthermore, the study aims to evaluate long-term prevalence of psychopathology in relatives. METHODS AND ANALYSES In this multicentre prospective cohort study, out-of-hospital cardiac arrest survivors and their relatives will be recruited. The post-arrest screening includes the Montreal Cognitive Assessment (MoCA), the Hospital Anxiety and Depression Scale (HADS), the Impact of Event Scale-Revised (IES-R) and the Acute Stress Disorder Interview (ASDI) and is conducted during hospitalisation. In a subsample of the patients, functional MRI is done, and cortisol determination collected. At 3-month follow-up, the primary study outcomes for 200 survivors include the Danish Affective Verbal Learning Test-26 (VAMT-26), Delis-Kaplan Executive Function System tests (trail making, colour-word interference, word and design fluency), Rey's Complex Figure and Letter-number sequencing subtest of Wechsler Adult Intelligence Scale-IV, HADS and IES-R. For the relatives, they include HADS and IES-R. ETHICS AND DISSEMINATION The study is approved by the local regional Research Ethics Committee (H-18046155) and the Danish Data Protection Agency (RH-2017-325, j.no.05961) and follows the latest version of the Declaration of Helsinki. The results will be published in peer-reviewed journals and may impact the follow-up of cardiac arrest survivors.
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Affiliation(s)
- Mette Kirstine Wagner
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Selina Kikkenborg Berg
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sophia Armand
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Ola Ekholm
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Syddanmark, Denmark
| | | | - Patrick MacDonald Fisher
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Center for Integrated Molecular Brain Imaging, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Gitte Moos Knudsen
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Center for Integrated Molecular Brain Imaging, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Dea Siggaard Stenbæk
- Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Long-term cognitive impairment after ICU treatment: a prospective longitudinal cohort study (Cog-I-CU). Sci Rep 2020; 10:15518. [PMID: 32968099 PMCID: PMC7511316 DOI: 10.1038/s41598-020-72109-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 08/21/2020] [Indexed: 01/16/2023] Open
Abstract
In this prospective cohort study we aimed to investigate the trajectory of the cognitive performance of patients after discharge from an intensive care unit (ICU). Special consideration was given to patients with suspected premorbid cognitive impairment who might be at risk for the development of dementia. Clinical characteristics were collected until discharge. The premorbid cognitive state was estimated by a structured interview with a close relative. Cognitive outcome was assessed using the Consortium to Establish a Registry of Alzheimer’s Disease (CERAD) Plus battery and the Stroop Color and Word Test at the time of discharge from ICU and 9 months later. The results of the study group were compared to an established healthy control group and to normative data. A total number of 108 patients were finally included. At the time of discharge, patients underperformed the healthy control group. In linear regression models, delirium during the ICU stay and the factor premorbid cognitive impairment were associated with poorer cognitive outcome (p = 0.047 and p = 0.001). After 9 months, in 6% of patients without evidence of premorbid cognitive impairment long-lasting deficits were found. In patients with suspected premorbid cognitive impairment, performance in tests of executive function failed to improve.
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Nedergaard HK, Jensen HI, Stylsvig M, Olsen HT, Strøm T, Toft P. Effect of non-sedation on post-traumatic stress and psychological health in survivors of critical illness-A substudy of the NONSEDA randomized trial. Acta Anaesthesiol Scand 2020; 64:1136-1143. [PMID: 32470147 DOI: 10.1111/aas.13648] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/23/2020] [Accepted: 05/10/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Critical illness can cause post-traumatic stress and impaired mental health. The NONSEDA trial was a Scandinavian multicenter RCT, assessing non-sedation versus sedation with a daily wake-up call during mechanical ventilation in critically ill adults. The aim of this substudy was to assess the effect of non-sedation on post-traumatic stress and mental health. METHODS This substudy is based on all participating patients from a single NONSEDA trial site (Kolding, Denmark). Patients were randomized to sedation or non-sedation within the first 24 hours of mechanical ventilation. Three months after ICU discharge survivors were examined by a neuropsychologist for post-traumatic stress, anxiety and depression, and filled out the SF-36 questionnaire regarding quality of life. RESULTS The two groups of survivors were similar with regard to baseline characteristics, length of admission and mechanical ventilation. Sedated patients received more propofol and midazolam. Doses of morphine and haloperidole were equal. PRIMARY OUTCOME the number of patients with post-traumatic stress disorder did not differ between groups (non-sedated: 2 patients vs sedated: 0, P = .23). SECONDARY OUTCOMES there were no differences between groups in Beck Anxiety Index (median, non-sedated: 0 vs sedated: 0, P = .62), Beck Depression Index (median, non-sedated: 7 vs sedated: 4, P = .24), SF-36 mental component score (mean, non-sedated: 46.7 vs sedated: 47.5, P = .73) or number of patients with symptoms of post-traumatic stress (8 in both groups, P = .89). CONCLUSION Levels of PTSD, anxiety and depression and quality of life regarding mental health were similar between the non-sedated and sedated group.
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Affiliation(s)
- Helene K. Nedergaard
- Department of Anesthesiology and Intensive Care Lillebaelt Hospital KoldingUniversity Hospital of Southern Denmark Kolding Denmark
- Department of Clinical Research University of Southern Denmark Odense Denmark
| | - Hanne I. Jensen
- Department of Anesthesiology and Intensive Care Lillebaelt Hospital KoldingUniversity Hospital of Southern Denmark Kolding Denmark
- Department of Regional Health Research University of Southern Denmark Odense Denmark
| | | | - Hanne T. Olsen
- Department of Clinical Research University of Southern Denmark Odense Denmark
- Department of Anesthesiology and Intensive Care Odense University Hospital Svendborg Denmark
| | - Thomas Strøm
- Department of Anesthesiology and Intensive Care Odense University Hospital Odense Denmark
| | - Palle Toft
- Department of Anesthesiology and Intensive Care Odense University Hospital Odense Denmark
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Wilcox ME, McAndrews MP, Van J, Jackson JC, Pinto R, Black SE, Lim AS, Friedrich JO, Rubenfeld GD. Sleep Fragmentation and Cognitive Trajectories After Critical Illness. Chest 2020; 159:366-381. [PMID: 32717265 DOI: 10.1016/j.chest.2020.07.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 06/30/2020] [Accepted: 07/08/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND ICU survivors can experience both cognitive dysfunction and persistent sleep disturbances after hospitalization. Sleep disturbances have been linked with cognitive impairment in various patient populations, and the apolipoprotein E (APOE) genotype has been linked to sleep-related impairments in cognition. RESEARCH QUESTION Is there an association between sleep, long-term cognition, and APOE status in ICU survivors? STUDY DESIGN AND METHODS We enrolled 150 patients from five centers who had been mechanically ventilated for at least 3 days; 102 patients survived to ICU discharge. Actigraphy and cognitive testing were undertaken at 7 days, 6 months, and 12 months after ICU discharge, and sleep duration, quality, and timing were estimated by actigraphy. APOE single nucleotide polymorphisms were assessed for each patient. RESULTS Actigraphy-estimated sleep fragmentation, but not total sleep time or interdaily stability (estimate of circadian rhythmicity), was associated with worse cognitive impairment at 7 days of ICU discharge. No actigraphy-estimated variable of sleep estimation at 7 days post-ICU discharge predicted cognitive impairment or persistent sleep abnormalities at 6 and 12 months of follow-up in subsequently assessed survivors. Possessing the APOE ε4 allele was not significantly associated with sleep disturbances and its presence did not modify the risk of sleep-related cognitive impairment at follow-up. INTERPRETATION Sleep fragmentation estimated by actigraphy was associated with worse cognitive performance in hospital, but not at later time intervals. Further research is needed to better delineate the relationship between persistent sleep disturbances and cognition in larger numbers of ICU survivors. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02086877; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Mary Elizabeth Wilcox
- Department of Medicine (Critical Care Medicine), University Health Network, Toronto, ON, Canada; Interdepartment Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| | - Mary Pat McAndrews
- Krembil Brain Institute, University Health Network and Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - Julie Van
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS Center), Nashville, TN; Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt Medical Center, Nashville, TN
| | - James C Jackson
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS Center), Nashville, TN; Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt Medical Center, Nashville, TN
| | - Ruxandra Pinto
- Interdepartment Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine (Critical Care Medicine), Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Sandra E Black
- Department of Medicine (Critical Care Medicine), Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - Andrew S Lim
- Department of Medicine (Neurology), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada
| | - Jan O Friedrich
- Interdepartment Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Critical Care and Medicine Departments and Li Ka Shing Knowledge Institute, University of Toronto, St. Michael's Hospital, Toronto, ON, Canada
| | - Gordon D Rubenfeld
- Interdepartment Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine (Critical Care Medicine), Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Kohler J, Borchers F, Endres M, Weiss B, Spies C, Emmrich JV. Cognitive Deficits Following Intensive Care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:627-634. [PMID: 31617485 DOI: 10.3238/arztebl.2019.0627] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 02/06/2019] [Accepted: 07/16/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Illnesses that necessitate intensive care can impair cognitive function severely over the long term, leaving patients less able to cope with the demands of everyday living and markedly lowering their quality of life. There has not yet been any comprehensive study of the cognitive sequelae of critical illness among non- surgical patients treated in intensive care. The purpose of this review is to present the available study findings on cognitive deficits in such patients, with particular at- tention to prevalence, types of deficit, clinical course, risk factors, prevention, and treatment. METHODS This review is based on pertinent publications retrieved by a selective search in MEDLINE. RESULTS The literature search yielded 3360 hits, among which there were 14 studies that met our inclusion criteria. 17-78% of patients had cognitive deficits after dis- charge from the intensive care unit; most had never had a cognitive deficit before. Cognitive impairment often persisted for up to several years after discharge (0.5 to 9 years) and tended to improve over time. The only definite risk factor is delirium. CONCLUSION Cognitive dysfunction is a common sequela of the treatment of non-surgical patients in intensive care units. It is a serious problem for the affected persons and an increasingly important socio-economic problem as well. The effective management of delirium is very important. General conclusions are hard to draw from the available data because of heterogeneous study designs, varying methods of measurement, and differences among patient cohorts. Further studies are needed so that study designs and clinical testing procedures can be standard- ized and effective measures for prevention and treatment can be identified.
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Affiliation(s)
- Joel Kohler
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin; Department of Anesthesiology and Operative Intensive Care Medicine at Campus Benjamin Franklin Charité-Universitätsmedizin Berlin
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Wang X, Xu X, Guo Y, Huang P, Ha Y, Zhang R, Bai Y, Cui X, He S, Liu Q. Qiang Xin 1 Formula Suppresses Excessive Pro-Inflammatory Cytokine Responses and Microglia Activation to Prevent Cognitive Impairment and Emotional Dysfunctions in Experimental Sepsis. Front Pharmacol 2020; 11:579. [PMID: 32457609 PMCID: PMC7225281 DOI: 10.3389/fphar.2020.00579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 04/15/2020] [Indexed: 12/30/2022] Open
Abstract
Sepsis commonly leads to acute and long-term cognitive and affective impairments which are associated with increased mortality in patients. Neuroinflammation characterized by excessive cytokine release and immune cell activation underlies the behavioral changes associated with sepsis. We previously reported that the administration of a traditional Chinese herbal Qiang Xin 1 (QX1) formula improves survival in septic mice. This study was performed to better understand the effects and the mechanisms of QX1 formula treatment on behavioral changes in a preclinical septic model induced by cecal ligation and puncture. Oral administration of QX1 formula significantly improved survival, alleviated overall cognitive impairment and emotional dysfunction as assessed by the Morris water maze, novel object recognition testing, elevated plus maze and open field testing in septic mice. QX1 formula administration dramatically inhibited short and long-term excessive pro-inflammatory cytokine production both peripherally and centrally, and was accompanied by diminished microglial activation in septic mice. Biological processes including synaptic transmission, microglia cell activation, cytokine production, microglia cell polarization, as well as inflammatory responses related to signaling pathways including the MAPK signaling pathway and the NF-κB signaling pathway were altered prominently by QX1 formula treatment in the hippocampus of septic mice. In addition, QX1 formula administration decreased the expression of the M1 phenotype microglia gene markers such as Cd32, Socs3, and Cd68, while up-regulated M2 phenotype marker genes including Myc, Arg-1, and Cd206 as revealed by microarray analysis and Real-time PCR. In conclusion, QX1 formula administration attenuates cognitive deficits, emotional dysfunction, and reduces neuroinflammatory responses to improve survival in septic mice. Diminished microglial activation and altered microglial polarization are involved in the neuroprotective mechanism of QX1 formula.
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Affiliation(s)
- Xuerui Wang
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Beijing Institute of Traditional Chinese Medicine, Beijing, China.,Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Xiaolong Xu
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Beijing Institute of Traditional Chinese Medicine, Beijing, China.,Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Yuhong Guo
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Po Huang
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Yanxiang Ha
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Rui Zhang
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Yunjing Bai
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Beijing Institute of Traditional Chinese Medicine, Beijing, China.,Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Xuran Cui
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Beijing Institute of Traditional Chinese Medicine, Beijing, China.,Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Shasha He
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Beijing Institute of Traditional Chinese Medicine, Beijing, China.,Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Qingquan Liu
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Beijing Institute of Traditional Chinese Medicine, Beijing, China.,Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
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Abstract
Introduction: Acute respiratory distress syndrome (ARDS) is a severe form of acute lung injury common in critically ill patients and characterized by significant morbidity and mortality. It frequently manifests long-lasting effects beyond hospitalization, from cognitive impairment to physical weakness.Areas covered: Several complications of ARDS have been identified in patients after hospital discharge. The authors conducted literature searches to identify observational studies, randomized clinical trials, systematic reviews, and guidelines. A summary of is presented here to outline the sequelae of ARDS and their risk factors with a focus on the limited but growing research into possible therapies. Long term sequelae of ARDS commonly identified in the literature include long-term cognitive impairment, psychological morbidities, neuromuscular weakness, pulmonary dysfunction, and ongoing healthcare utilization with reduced quality of life.Expert opinion: Given the public health significance of long-term complications following ARDS, the development of new therapies for prevention and treatment is of vital importance. Furthering knowledge of the pathophysiology of these impairments will provide a framework to develop new therapeutic targets to fuel future clinical trials in this area of critical care medicine.
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Affiliation(s)
- Matthew F Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
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Sepsis-Associated Encephalopathy: From Delirium to Dementia? J Clin Med 2020; 9:jcm9030703. [PMID: 32150970 PMCID: PMC7141293 DOI: 10.3390/jcm9030703] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 02/20/2020] [Accepted: 03/03/2020] [Indexed: 12/12/2022] Open
Abstract
Sepsis is a major cause of death in intensive care units worldwide. The acute phase of sepsis is often accompanied by sepsis-associated encephalopathy, which is highly associated with increased mortality. Moreover, in the chronic phase, more than 50% of surviving patients suffer from severe and long-term cognitive deficits compromising their daily quality of life and placing an immense burden on primary caregivers. Due to a growing number of sepsis survivors, these long-lasting deficits are increasingly relevant. Despite the high incidence and clinical relevance, the pathomechanisms of acute and chronic stages in sepsis-associated encephalopathy are only incompletely understood, and no specific therapeutic options are yet available. Here, we review the emergence of sepsis-associated encephalopathy from initial clinical presentation to long-term cognitive impairment in sepsis survivors and summarize pathomechanisms potentially contributing to the development of sepsis-associated encephalopathy.
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Brown SM, Beesley SJ, Stubben C, Wilson EL, Presson AP, Grissom C, Maguire C, Rondina MT, Hopkins RO. Postseptic Cognitive Impairment and Expression of APOE in Peripheral Blood: The Cognition After SepsiS (CASS) Observational Pilot Study. J Intensive Care Med 2020; 36:262-270. [PMID: 31916880 PMCID: PMC8721590 DOI: 10.1177/0885066619897604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Cognitive impairment after sepsis is an important clinical problem. Determinants of postseptic cognitive impairment are not well understood. We thus undertook a systems biology approach to exploring a possible role for apolipoprotein E (APOE) in postseptic cognitive impairment. DESIGN Prospective, observational cohort. SETTING Intermountain Medical Center, a tertiary referral center in Utah. PATIENTS/PARTICIPANTS Patients with sepsis admitted to study intensive care units. INTERVENTIONS None. METHODS We obtained peripheral blood for deep sequencing of RNA and followed up survivors at 6 months with a battery of cognitive instruments. We defined cognitive impairment based on the 6-month Hayling test of executive function. In our primary analysis, we employed weighted network analysis. Secondarily, we compared variation in gene expression between patients with normal versus impaired cognition. MEASUREMENTS AND MAIN RESULTS We enrolled 40 patients, of whom 34 were follow-up eligible and 31 (91%) completed follow-up; 1 patient's RNA sample was degraded-the final analytic cohort was 30 patients. Mean Hayling test score was 5.8 (standard deviation 1.1), which represented 20% with impaired executive function. The network module containing APOE was dominated by low-expression genes, with no association on primary analysis (P = .8). Secondary analyses suggested several potential lines of future investigation, including oxidative stress. CONCLUSIONS In this prospective pilot cohort, executive dysfunction affected 1 in 5 survivors of sepsis. The APOE gene was sparsely transcribed in peripheral leukocytes and not associated with cognitive impairment. Future lines of research are suggested.
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Affiliation(s)
- Samuel M Brown
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT, USA.,Department of Medicine, Pulmonary and Critical Care Division, 98078Intermountain Medical Center, Murray, UT, USA.,Department of Medicine, Pulmonary and Critical Care Division, 7060University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Sarah J Beesley
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT, USA.,Department of Medicine, Pulmonary and Critical Care Division, 98078Intermountain Medical Center, Murray, UT, USA.,Department of Medicine, Pulmonary and Critical Care Division, 7060University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Chris Stubben
- Bioinformatics Shared Resource, 20270Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Emily L Wilson
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT, USA.,Department of Medicine, Pulmonary and Critical Care Division, 98078Intermountain Medical Center, Murray, UT, USA
| | - Angela P Presson
- Division of Epidemiology, Study Design and Biostatistics Center, 7060University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Colin Grissom
- Department of Medicine, Pulmonary and Critical Care Division, 98078Intermountain Medical Center, Murray, UT, USA.,Department of Medicine, Pulmonary and Critical Care Division, 7060University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Colin Maguire
- Center for Translational and Clinical Sciences, 7060University of Utah, Salt Lake City, UT, USA.,University of Utah Molecular Medicine Program, 7060University of Utah, Salt Lake City, UT USA.,Departments of Internal Medicine and Pathology, 7060University of Utah, Salt Lake City, UT USA
| | - Matthew T Rondina
- University of Utah Molecular Medicine Program, 7060University of Utah, Salt Lake City, UT USA.,Departments of Internal Medicine and Pathology, 7060University of Utah, Salt Lake City, UT USA.,Department of Internal Medicine and the GRECC, George E. Wahlen VAMC, Salt Lake City, UT, USA
| | - Ramona O Hopkins
- Center for Humanizing Critical Care, Intermountain Healthcare, Murray, UT, USA.,Department of Medicine, Pulmonary and Critical Care Division, 98078Intermountain Medical Center, Murray, UT, USA.,Department of Psychology and Neuroscience Center, Brigham Young University, Provo, UT, USA
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Lee Y, Kim K, Lim C, Kim JS. Effects of the ABCDE bundle on the prevention of post-intensive care syndrome: A retrospective study. J Adv Nurs 2019; 76:588-599. [PMID: 31729768 DOI: 10.1111/jan.14267] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 10/27/2019] [Accepted: 11/07/2019] [Indexed: 11/30/2022]
Abstract
AIM To identify the effects of each domain of the early and modified ABCDE bundle on post-intensive care syndrome (PICS). DESIGN This is a retrospective study. METHODS We analysed the data from electronic medical records of 91 intensive care patients who received therapeutic interventions in stages, based on the early ABCDE bundle (admitted to the intensive care unit [ICU] from June - August 2013) and 94 patients who received interventions using a modified ABCDE bundle developed through continuous quality improvement activities (admitted to the ICU from June to August 2014). RESULTS In the ABC domain, the percentage of patients showing sedation levels of alertness and calmness increased significantly from 58.2% using the early ABCDE bundle to 72.4% using the modified ABCDE bundle. Coma prevalence decreased significantly from 45.1% using the early ABCDE bundle to 28.7% using the modified ABCDE bundle. In the E domain, the percentage of patients receiving early mobility interventions increased significantly from 11% using the early ABCDE bundle to 54.3% using the modified ABCDE bundle. CONCLUSION The ABCDE bundle in the ICU helped prevent PICS by reducing deep sedation and immobilization among intensive care patients. To effectively use the ABCDE bundle, it is necessary for institutions to develop suitable protocols for each constituent element and to test their effectiveness. IMPACT The ABCDE bundle was a suitable tool to support evidence-based practice in intensive care patients, including oversedation and immobilization, which is related to the prevention of PICS. Individual institutions will need to actively use the ABCDE bundle in the ICU, by developing protocols and testing their effectiveness.
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Affiliation(s)
- YoonMi Lee
- Department of Nursing, Samgsung Medical Center, Seoul, Republic of Korea
| | - Kyunghee Kim
- Department of Nursing, Chung-Ang University, Seoul, Republic of Korea
| | - Changwon Lim
- Department of Applied Statistics, Chung-Ang University, Seoul, Republic of Korea
| | - Ji-Su Kim
- Department of Nursing, Chung-Ang University, Seoul, Republic of Korea
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36
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Abstract
PURPOSE OF REVIEW Evaluating longer term mortality, morbidity, and quality of life in survivors of critical illness is a research priority. This review details the challenges of long-term follow-up studies of critically ill patients and highlights recently proposed methodological solutions. RECENT FINDINGS Barriers to long-term follow-up studies of critical care survivors include high rates of study attrition because of death or loss to follow-up, data missingness from experienced morbidity, and lack of standardized outcome as well as reporting of key covariates. A number of recent methods have been proposed to reduce study patients attrition, including minimum data set selection and visits to transitional care or home settings, yet these have significant downsides as well. Conducting long-term follow-up even in the absence of such models carries a high expense, as personnel are very costly, and patients/families require reimbursement for their time and inconvenience. SUMMARY There is a reason why many research groups do not conduct long-term outcomes in critical care: it is very difficult. Challenges of long-term follow-up require careful consideration by study investigators to ensure our collective success in data integration and a better understanding of underlying mechanisms of mortality and morbidity seen in critical care survivorship.
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Affiliation(s)
- M. Elizabeth Wilcox
- Department of Medicine (Critical Care Medicine), Division of Respirology, University Health Network, Toronto, Canada
- Interdepartment Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine and Center for Health Services Research, Department of Medicine, and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
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37
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Maddux AB, Zimmerman JJ. Awake or Sedate . . . Do We Know the Best State? Am J Respir Crit Care Med 2019; 197:1378-1380. [PMID: 29365272 DOI: 10.1164/rccm.201801-0044ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Aline B Maddux
- 1 Section of Pediatric Critical Care Medicine University of Colorado School of Medicine Aurora, Colorado.,2 Children's Hospital Colorado Aurora, Colorado
| | - Jerry J Zimmerman
- 3 Division of Pediatric Critical Care Medicine Seattle Children's Hospital Seattle, Washington and.,4 Harborview Medical Center University of Washington School of Medicine Seattle, Washington
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38
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Kaku S, Nguyen CD, Htet NN, Tutera D, Barr J, Paintal HS, Kuschner WG. Acute Respiratory Distress Syndrome: Etiology, Pathogenesis, and Summary on Management. J Intensive Care Med 2019; 35:723-737. [DOI: 10.1177/0885066619855021] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The acute respiratory distress syndrome (ARDS) has multiple causes and is characterized by acute lung inflammation and increased pulmonary vascular permeability, leading to hypoxemic respiratory failure and bilateral pulmonary radiographic opacities. The acute respiratory distress syndrome is associated with substantial morbidity and mortality, and effective treatment strategies are limited. This review presents the current state of the literature regarding the etiology, pathogenesis, and management strategies for ARDS.
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Affiliation(s)
- Shawn Kaku
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Christopher D. Nguyen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Natalie N. Htet
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Dominic Tutera
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Juliana Barr
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Harman S. Paintal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Ware G. Kuschner
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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Yuan J, Yang MC, Wu MJ, Gou YS. Sedative depth on neurological outcomes in a juvenile rat model of cardiopulmonary resuscitation. Med Hypotheses 2019; 132:109233. [PMID: 31606702 DOI: 10.1016/j.mehy.2019.109233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 05/11/2019] [Accepted: 05/18/2019] [Indexed: 01/26/2023]
Abstract
The guidelines for cardiopulmonary resuscitation (CPR) in pediatric advanced life support suggest that midazolam is the preferred agent for sedation in patients with mild hypothermia, whereas children with cardiac arrest (CA) are at a crucial stage regarding their immature nervous system. Studies have shown that midazolam may have a detrimental effect on the developmental of the pediatric nervous system. Our previous study found that midazolam induced neuronal damage after CPR in young rats. It is speculated that: midazolam causes the potential injury of neurons by inhibiting mitochondrial autophagy expression and is an important factor for the poor prognosis in children after successful CPR. This project intends to adopt the modified asphyxiant CPR model in juvenile rats. Survival rate, neurological function and histopathological changes were evaluated to determine the protective effects of appropriate sedation depth on cerebral ischemia-reperfusion injury in juvenile rats after CPR. Combined with cell biology and molecular biology related technologies, the mechanism by which the mitochondrial pinkl-parkin signaling pathway induces autophagy to inhibit neuronal apoptosis may be key factor in the protective effects of sedation depth on the brain. The aim of this study is to provide experimental evidence and elucidate the mechanisms of improvement of cerebral ischemia-reperfusion injury by sedation depth in children after successful CPR and to lay a theoretical and experimental basis for clinical treatment.
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Affiliation(s)
- Jing Yuan
- The Third People(')s Hospital of Chengdu, The Affiliated Hospital of Southwest Jiaotong University, China
| | - Meng-Chang Yang
- Department of Anesthesiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu 610072, Sichuan, China
| | - Meng-Jun Wu
- Department of Anesthesiology, Chengdu Women and Children(')s Central Hospital, Chengdu 610041, Sichuan, China.
| | - Yong-Sheng Gou
- Department of Orthopedics, Shuangliu First People's Hospital, Chengdu 610200, Sichuan, China.
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40
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Aragón RE, Proaño A, Mongilardi N, de Ferrari A, Herrera P, Roldan R, Paz E, Jaymez AA, Chirinos E, Portugal J, Quispe R, Brower RG, Checkley W. Sedation practices and clinical outcomes in mechanically ventilated patients in a prospective multicenter cohort. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:130. [PMID: 30995940 PMCID: PMC6472077 DOI: 10.1186/s13054-019-2394-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 03/15/2019] [Indexed: 12/27/2022]
Abstract
Objectives We sought to study the association between sedation status, medications (benzodiazepines, opioids, and antipsychotics), and clinical outcomes in a resource-limited setting. Design A longitudinal study of critically ill participants on mechanical ventilation. Setting Five intensive care units (ICUs) in four public hospitals in Lima, Peru. Patients One thousand six hundred fifty-seven critically ill participants were assessed daily for sedation status during 28 days and vital status by day 90. Results After excluding data of participants without a Richmond Agitation Sedation Scale score and without sedation, we followed 1338 (81%) participants longitudinally for 18,645 ICU days. Deep sedation was present in 98% of participants at some point of the study and in 12,942 ICU days. Deep sedation was associated with higher mortality (interquartile odds ratio (OR) = 5.42, 4.23–6.95; p < 0.001) and a significant decrease in ventilator (− 7.27; p < 0.001), ICU (− 4.38; p < 0.001), and hospital (− 7.00; p < 0.001) free days. Agitation was also associated with higher mortality (OR = 39.9, 6.53–243, p < 0.001). The most commonly used sedatives were opioids and benzodiazepines (9259 and 8453 patient days respectively), and the latter were associated with a 41% higher mortality in participants with a higher cumulative dose (75th vs 25th percentile, interquartile OR = 1.41, 1.12–1.77; p < 0.01). The overall cumulative dose of benzodiazepines and opioids was high, 774.5 mg and 16.8 g, respectively, by day 7 and by day 28; these doses approximately doubled. Haloperidol was only used in 3% of ICU days; however, the use of it was associated with a 70% lower mortality (interquartile OR = 0.3, 0.22–0.44, p < 0.001). Conclusions Deep sedation, agitation, and cumulative dose of benzodiazepines were all independently associated with higher 90-day mortality. Additionally, deep sedation was associated with less ventilator-, ICU-, and hospital-free days. In contrast, haloperidol was associated with lower mortality in our study. Electronic supplementary material The online version of this article (10.1186/s13054-019-2394-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Romina E Aragón
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1830 E Monument St., Suite 555, Baltimore, MD, 21287, USA.,Escuela Profesional de Medicina, Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Alvaro Proaño
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1830 E Monument St., Suite 555, Baltimore, MD, 21287, USA.,Escuela Profesional de Medicina, Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Nicole Mongilardi
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1830 E Monument St., Suite 555, Baltimore, MD, 21287, USA.,Unidad de Conocimiento y Evidencia, Universidad Peruano Cayetano Heredia, Lima, Peru
| | - Aldo de Ferrari
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1830 E Monument St., Suite 555, Baltimore, MD, 21287, USA
| | - Phabiola Herrera
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1830 E Monument St., Suite 555, Baltimore, MD, 21287, USA
| | - Rollin Roldan
- Servicio De Cuidados Intensivos, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Enrique Paz
- Servicio De Cuidados Intensivos, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - Amador A Jaymez
- Servicio De Cuidados Intensivos, Hospital Nacional Arzobispo Loayza, Lima, Peru
| | - Eduardo Chirinos
- Servicio De Cuidados Intensivos, Hospital De Emergencias José Casimiro Ulloa, Lima, Peru
| | - Jose Portugal
- Servicio De Cuidados Intensivos, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Rocio Quispe
- Servicio De Cuidados Intensivos, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
| | - Roy G Brower
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1830 E Monument St., Suite 555, Baltimore, MD, 21287, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, 1830 E Monument St., Suite 555, Baltimore, MD, 21287, USA. .,Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA.
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Proffitt T, Menzies V. Relationship of symptoms associated with ICU-survivorship: An integrative literature review. Intensive Crit Care Nurs 2019; 53:60-67. [PMID: 30878537 DOI: 10.1016/j.iccn.2019.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/23/2019] [Accepted: 02/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The number of adults who survive a critical illness involving admission to an intensive care unit is increasing. These survivors have an increased risk of developing impairments in cognition, physical function and psychological health. OBJECTIVE This integrative literature review examined the literature for studies exploring the relationships among two or more of the variables of interest, i.e. cognitive, physical, and psychological symptoms (depressive, anxiety, or posttraumatic stress) in intensive care unit survivors post-hospital discharge. METHODS A literature search was conducted using PubMed, CINHAL and PsycINFO databases. FINDINGS While all 13 studies included in the review explored some aspect of a relationship among the variables of interest, none explored associations among all three variables. Five studies explored physical function and psychological symptoms, four studies explored cognitive impairment and psychological symptoms and five studies explored the association among different psychological symptoms. Inconsistencies were found in the study designs, follow-up time frames, patient populations and measures used. CONCLUSIONS Further research using well-designed methodologies and standardized instruments is warranted. Gaining a better understanding of the relationships among these impairments has the potential to contribute to the development of screening guidelines, preventative strategies, and treatments.
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Affiliation(s)
- Tracye Proffitt
- Virginia Commonwealth University School of Nursing, 1100 East Leigh Street, Box 980567, Richmond, VA 23298-0567, United States.
| | - Victoria Menzies
- Virginia Commonwealth University School of Nursing, 1100 East Leigh Street, Box 980567, Richmond, VA 23298-0567, United States
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42
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Koutsogiannaki S, Shimaoka M, Yuki K. The Use of Volatile Anesthetics as Sedatives for Acute Respiratory Distress Syndrome. ACTA ACUST UNITED AC 2019; 6:27-38. [PMID: 30923729 PMCID: PMC6433148 DOI: 10.31480/2330-4871/084] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Acute respiratory distress syndrome (ARDS) remains to pose a high morbidity and mortality without any targeted therapies. Sedation, usually given intravenously, is an important part of clinical practice in intensive care unit (ICU), and the effect of sedatives on patients’ outcomes has been studied intensively. Although volatile anesthetics are not routine sedatives in ICU, preclinical and clinical studies suggested their potential benefit in pulmonary pathophysiology. This review will summarize the current knowledge of ARDS and the role of volatile anesthetic sedation in this setting from both clinical and mechanistic standpoints. In addition, we will review the infrastructure to use volatile anesthetics.
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Affiliation(s)
- Sophia Koutsogiannaki
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA.,Department of Anesthesiology, Critical Care and Pain Medicine, Cardiac Anesthesia Division, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Motomu Shimaoka
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Tsushi, Mie, Japan
| | - Koichi Yuki
- Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA.,Department of Anesthesiology, Critical Care and Pain Medicine, Cardiac Anesthesia Division, Boston Children's Hospital, Boston, Massachusetts, USA
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Wang W, Liu Y, Liu Y, Liu F, Ma Y. Comparison of Cognitive Impairments After Intensive Care Unit Sedation Using Dexmedetomidine and Propofol Among Older Patients. J Clin Pharmacol 2019; 59:821-828. [PMID: 30624767 DOI: 10.1002/jcph.1372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 12/10/2018] [Indexed: 12/31/2022]
Abstract
Despite the high prevalence of cognitive impairment among older adults, little is known about the association of the selection of dexmedetomidine and propofol on cognitive functions of patients after a critical illness. Patients aged ≥70 years who received intensive care unit (ICU) care from Cangzhou Central Hospital between 2013 and 2016 were enrolled and randomized into a dexmedetomidine group and a propofol group with matched demographic and clinical characteristics. At discharge from the ICU and 4 weeks later, the cognitive status of patients was assessed and compared using the Montreal Cognitive Assessment system. There were 164 patients included in the dexmedetomidine group and 159 patients in the propofol group. No significant difference was observed between the 2 groups in terms of age, female sex, body weight, educational level, ICU and hospital stay, comorbidities, and medications. Further, patients from the 2 groups at ICU discharge did not demonstrate significant difference on the Montreal Cognitive Assessment component scores, which showed significant differences between the 2 groups 4 weeks later (P < .05). Moreover, dexmedetomidine and propofol showed different levels of impacts on the cognitive function of patients discharged from the postanesthesia care unit, neurological ICU, and medical ICU. This study demonstrated that patients discharged from the ICU who received propofol for sedation showed less impairment on the cognitive functions when compared with patients who received dexmedetomidine during ICU care 4 weeks after discharge. Despite some limitations, this study provides insights to the decision-making process in the selection of appropriate sedation strategy, especially for the elderly patients.
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Affiliation(s)
- Wenhao Wang
- Department of Internal Medicine, Cangzhou Central Hospital, Hebei, China
| | - Yi Liu
- Cangzhou Prison, Hebei, China
| | - Yunfeng Liu
- Department of Internal Medicine, Cangzhou Central Hospital, Hebei, China
| | - Feifei Liu
- Department of Internal Medicine, Cangzhou People's Hospital, China
| | - Yuxia Ma
- Department of Internal Medicine, Cangzhou Central Hospital, Hebei, China
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Montgomery H, Grocott M, Mythen M. Critical care at the end of life: balancing technology with compassion and agreeing when to stop. Br J Anaesth 2019; 119:i85-i89. [PMID: 29161388 DOI: 10.1093/bja/aex324] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Modern intensive care saves lives. However, the substantial related financial costs are, for many, married to substantial costs in terms of suffering. In the most sick, the experience of intensive care is commonly associated with the development of profound physical debility, which may last years after discharge. Likewise, the negative psychological impact commonly experienced by such patients during their care is now widely recognized, as is the persistence of psychological morbidity. Such issues become increasingly important as the population of the frail elderly increases, and the health and social care services face budgetary restriction. Efforts must be made to humanize intensive care as much as possible. Meanwhile, an open conversation must be held between those within the medical professions, and between such healthcare workers and the public in general, regarding the balancing of the positive and negative impacts of intensive care. Such conversations should extend to individual patients and their families when considering what care is genuinely in their best interests.
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Affiliation(s)
- H Montgomery
- Department of Intensive Care Medicine, University College London, London, UK
| | - M Grocott
- Department of Anaesthesia and Critical Care Medicine, Critical Care University of Southampton, Southampton, UK
| | - M Mythen
- Department of Anaesthesia and Critical Care, University College London, London, UK
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Abstract
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.
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Affiliation(s)
- Nathan E Brummel
- Department of Medicine, Vanderbilt University Medical Center, Center for Quality Aging, Suite 350, 2525 West End Avenue, Nashville, TN 37203, USA.
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Boncyk C, Nahrwold DA, Hughes CG. Targeting light versus deep sedation for patients receiving mechanical ventilation. JOURNAL OF EMERGENCY AND CRITICAL CARE MEDICINE (HONG KONG, CHINA) 2018; 2:79. [PMID: 30443646 PMCID: PMC6233900 DOI: 10.21037/jeccm.2018.10.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Christina Boncyk
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Daniel A. Nahrwold
- Department of Anesthesiology, Moffitt Cancer Center, Florida, USA
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Christopher G. Hughes
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, USA
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Abstract
BACKGROUND Intensive care unit patients undergoing mechanical ventilation have traditionally been sedated to make them comfortable and to avoid pain and anxiety. However, this may lead to prolonged mechanical ventilation and a longer length of stay. OBJECTIVE The aim of this retrospective study was to explore whether different sedation regimens influence the course and duration of the weaning process. PATIENTS AND METHODS Intubated adult patients (n = 152) from 15 general intensive care units in Sweden were mechanically ventilated for ≥ 24 h. Patients were divided into three groups according to the sedative(s) received during the weaning period (i.e. from being assessed as 'fit for weaning' until extubation): dexmedetomidine alone (DEX group, n = 32); standard of care with midazolam and/or propofol (SOC group, n = 67); or SOC plus dexmedetomidine (SOCDEX group, n = 53). RESULTS Patients receiving dexmedetomidine alone were weaned more rapidly than those in the other groups despite spending longer time on mechanical ventilation prior to weaning. Anxiety during weaning was present in 0, 9 and 24% patients in the DEX, SOC and SOCDEX groups, respectively. Anxiety after extubation was present in 41, 20 and 34% in the DEX, SOC and SOCDEX groups, respectively. Delirium during weaning was present in 1, 2 and 1 patient in the DEX, SOC and SOCDEX groups, respectively. Delirium at ICU discharge was present in 1, 0 and 3 patients in the DEX, SOC and SOCDEX groups, respectively. Few patients fulfilled criteria for post-traumatic stress disorder. CONCLUSION Dexmedetomidine, used as a single sedative, may have contributed to a shorter weaning period than SOC or SOCDEX. Patients who received dexmedetomidine-only sedation tended to report better health-related quality of life than those receiving other forms of sedation.
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Preliminary Validation of the Montreal Cognitive Assessment Tool among Sepsis Survivors: A Prospective Pilot Study. Ann Am Thorac Soc 2018; 15:1108-1110. [DOI: 10.1513/annalsats.201804-233oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Heins SE, Wozniak AW, Colantuoni E, Sepulveda KA, Mendez-Tellez PA, Dennison-Himmelfarb C, Needham DM, Dinglas VD. Factors associated with missed assessments in a 2-year longitudinal study of acute respiratory distress syndrome survivors. BMC Med Res Methodol 2018; 18:55. [PMID: 29907087 PMCID: PMC6003179 DOI: 10.1186/s12874-018-0508-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 05/09/2018] [Indexed: 01/17/2023] Open
Abstract
Background To evaluate participant-related variables associated with missing assessment(s) at follow-up visits during a longitudinal research study. Methods This is a prospective, longitudinal, multi-site study of 196 acute respiratory distress syndrome (ARDS) survivors. More than 30 relevant sociodemographic, physical status, and mental health variables (representing participant characteristics prior to ARDS, at hospital discharge, and at the immediately preceding follow-up visit) were evaluated for association with missed assessments at 3, 6, 12, and 24-month follow-up visits (89–95% retention rates), using binomial logistic regression. Results Most participants were male (56%), white (58%), and ≤ high school education (64%). Sociodemographic characteristics were not associated with missed assessments at the initial 3-month visit or subsequent visits. The number of dependencies in Activities of Daily Living (ADLs) at hospital discharge was associated with higher odds of missed assessments at the initial visit (OR: 1.26, 95% CI: 1.12, 1.43). At subsequent 6-, 12-, and 24 months visits, post-hospital discharge physical and psychological status were not associated with subsequent missed assessments. Instead, the following were associated with lower odds of missed assessments: indicators of poorer health prior to hospital admission (inability to walk 5 min (OR: 0.46; 0.23, 0.91), unemployment due to health (OR: 0.47; 0.23, 0.96), and alcohol abuse (OR: 0.53; 0.28, 0.97)) and having the preceding visit at the research clinic rather than at home/facility, or by phone/mail (OR: 0.54; 0.31, 0.96). Inversely, variables associated with higher odds of missed assessments at subsequent visits include: functional dependency prior to hospital admission (i.e. dependency with > = 2 Instrumental Activities of Daily Living (IADLs) (OR: 1.96; 1.08, 3.52), and missing assessments at preceding visit (OR: 2.26; 1.35, 3.79). Conclusions During the recovery process after hospital discharge, dependencies in physical functioning (e.g. ADLs, IADLs) prior to hospitalization and at hospital discharge were associated with higher odds of missed assessments. Conversely, other indicators of poorer health at baseline were associated with lower odds of missed assessments after the initial post-discharge visit. To reduce missing assessments, longitudinal clinical research studies may benefit from focusing additional resources on participants with dependencies in physical functioning prior to hospitalization and at hospital discharge. Electronic supplementary material The online version of this article (10.1186/s12874-018-0508-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sara E Heins
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amy W Wozniak
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Outcomes After Critical Illness and Surgery Group, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth Colantuoni
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Outcomes After Critical Illness and Surgery Group, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kristin A Sepulveda
- Outcomes After Critical Illness and Surgery Group, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument Street, 5th floor, Baltimore, MD, 21287, USA
| | - Pedro A Mendez-Tellez
- Outcomes After Critical Illness and Surgery Group, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Cheryl Dennison-Himmelfarb
- Outcomes After Critical Illness and Surgery Group, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins University School of Nursing, Johns Hopkins University, Baltimore, MD, USA.,Johns Hopkins Institute for Clinical and Translational Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Dale M Needham
- Outcomes After Critical Illness and Surgery Group, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument Street, 5th floor, Baltimore, MD, 21287, USA.,Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Victor D Dinglas
- Outcomes After Critical Illness and Surgery Group, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument Street, 5th floor, Baltimore, MD, 21287, USA.
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