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Formenti P, Sabbatini G, Brenna G, Galimberti A, Mattei L, Umbrello M, Iezzi M, Uldedaj E, Pezzi A, Gotti M. Foot drop in critically ill patients: a narrative review of an elusive complication with intricate implications for recovery and rehabilitation. Minerva Anestesiol 2024; 90:539-549. [PMID: 38551615 DOI: 10.23736/s0375-9393.24.17912-6] [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: 06/14/2024]
Abstract
Foot drop is a condition characterized by the inability to lift the foot upwards towards the shin bone. This condition may affect a proportion of critically ill patients, impacting on their recovery after the acute phase of the illness. The occurrence of foot drop in critical care patients may result from various underlying causes, including neurological injuries, muscular dysfunction, nerve compression, or vascular compromise. Understanding the etiology and assessing the severity of foot drop in these patients is essential for implementing appropriate management strategies and ensuring better patient outcomes. In this comprehensive review, we explore the complexities of foot drop in critically ill patients. We search for the potential risk factors that contribute to its development during critical illness, the impact it has on patients' functional abilities, and the various diagnostic techniques adopted to evaluate its severity. Additionally, we discuss current treatment approaches, rehabilitation strategies, and preventive measures to mitigate the adverse effects of foot drop in the critical care setting. Furthermore, we explore the roles of critical care physical therapists, neurologists, and other healthcare professionals in the comprehensive care of patients with foot drop syndrome and in such highlighting the importance of a multidisciplinary approach.
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Affiliation(s)
- Paolo Formenti
- Unit of Anesthesia and Resuscitation, ASST Nord Milano, Bassini Hospital, Cinisello Balsamo, Milan, Italy -
| | - Giovanni Sabbatini
- Unit of Anesthesia and Resuscitation, ASST Nord Milano, Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Giovanni Brenna
- Unit of Anesthesia and Resuscitation, ASST Nord Milano, Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Andrea Galimberti
- Unit of Anesthesia and Resuscitation, ASST Nord Milano, Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Luca Mattei
- Department of Neurosurgery, C. Besta IRCCS National Neurologic Institute Foundation, Milan, Italy
| | - Michele Umbrello
- Department of Intensive Care, New Hospital of Legnano, Legnano, Milan, Italy
| | - Massimiliano Iezzi
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Ersil Uldedaj
- Unit of Anesthesia, Resuscitation and Intensive Therapy, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan, Italy
| | - Angelo Pezzi
- Unit of Anesthesia and Resuscitation, ASST Nord Milano, Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Miriam Gotti
- Unit of Anesthesia and Resuscitation, ASST Nord Milano, Bassini Hospital, Cinisello Balsamo, Milan, Italy
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2
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Iavarone IG, Al-Husinat L, Vélez-Páez JL, Robba C, Silva PL, Rocco PRM, Battaglini D. Management of Neuromuscular Blocking Agents in Critically Ill Patients with Lung Diseases. J Clin Med 2024; 13:1182. [PMID: 38398494 PMCID: PMC10889521 DOI: 10.3390/jcm13041182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/09/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024] Open
Abstract
The use of neuromuscular blocking agents (NMBAs) is common in the intensive care unit (ICU). NMBAs have been used in critically ill patients with lung diseases to optimize mechanical ventilation, prevent spontaneous respiratory efforts, reduce the work of breathing and oxygen consumption, and avoid patient-ventilator asynchrony. In patients with acute respiratory distress syndrome (ARDS), NMBAs reduce the risk of barotrauma and improve oxygenation. Nevertheless, current guidelines and evidence are contrasting regarding the routine use of NMBAs. In status asthmaticus and acute exacerbation of chronic obstructive pulmonary disease, NMBAs are used in specific conditions to ameliorate patient-ventilator synchronism and oxygenation, although their routine use is controversial. Indeed, the use of NMBAs has decreased over the last decade due to potential adverse effects, such as immobilization, venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, ICU-acquired weakness, and residual paralysis after cessation of NMBAs use. The aim of this review is to highlight current knowledge and synthesize the evidence for the effects of NMBAs for critically ill patients with lung diseases, focusing on patient-ventilator asynchrony, ARDS, status asthmaticus, and chronic obstructive pulmonary disease.
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Affiliation(s)
- Ida Giorgia Iavarone
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, 16132 Genova, Italy
| | - Lou’i Al-Husinat
- Department of Clinical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Jorge Luis Vélez-Páez
- Facultad de Ciencias Médicas, Universidad Central de Ecuador, Quito 170129, Ecuador;
- Unidad de Terapia Intensiva, Hospital Pablo Arturo Suárez, Centro de Investigación Clínica, Quito 170129, Ecuador
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
- Department of Surgical Sciences and Integrated Diagnostics, University of Genova, 16132 Genova, Italy
- Facultad de Ciencias Médicas, Universidad Central de Ecuador, Quito 170129, Ecuador;
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil; (P.L.S.); (P.R.M.R.)
| | - Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy; (I.G.I.); (C.R.)
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Grotberg JC, Reynolds D, Kraft BD. Management of severe acute respiratory distress syndrome: a primer. Crit Care 2023; 27:289. [PMID: 37464381 DOI: 10.1186/s13054-023-04572-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/10/2023] [Indexed: 07/20/2023] Open
Abstract
This narrative review explores the physiology and evidence-based management of patients with severe acute respiratory distress syndrome (ARDS) and refractory hypoxemia, with a focus on mechanical ventilation, adjunctive therapies, and veno-venous extracorporeal membrane oxygenation (V-V ECMO). Severe ARDS cases increased dramatically worldwide during the Covid-19 pandemic and carry a high mortality. The mainstay of treatment to improve survival and ventilator-free days is proning, conservative fluid management, and lung protective ventilation. Ventilator settings should be individualized when possible to improve patient-ventilator synchrony and reduce ventilator-induced lung injury (VILI). Positive end-expiratory pressure can be individualized by titrating to best respiratory system compliance, or by using advanced methods, such as electrical impedance tomography or esophageal manometry. Adjustments to mitigate high driving pressure and mechanical power, two possible drivers of VILI, may be further beneficial. In patients with refractory hypoxemia, salvage modes of ventilation such as high frequency oscillatory ventilation and airway pressure release ventilation are additional options that may be appropriate in select patients. Adjunctive therapies also may be applied judiciously, such as recruitment maneuvers, inhaled pulmonary vasodilators, neuromuscular blockers, or glucocorticoids, and may improve oxygenation, but do not clearly reduce mortality. In select, refractory cases, the addition of V-V ECMO improves gas exchange and modestly improves survival by allowing for lung rest. In addition to VILI, patients with severe ARDS are at risk for complications including acute cor pulmonale, physical debility, and neurocognitive deficits. Even among the most severe cases, ARDS is a heterogeneous disease, and future studies are needed to identify ARDS subgroups to individualize therapies and advance care.
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Affiliation(s)
- John C Grotberg
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA.
| | - Daniel Reynolds
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Bryan D Kraft
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
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4
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De Bels D, Bousbiat I, Perriens E, Blackman S, Honoré PM. Sedation for adult ICU patients: A narrative review including a retrospective study of our own data. Saudi J Anaesth 2023; 17:223-235. [PMID: 37260674 PMCID: PMC10228859 DOI: 10.4103/sja.sja_905_22] [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] [Received: 12/29/2022] [Revised: 01/06/2023] [Accepted: 01/19/2023] [Indexed: 06/02/2023] Open
Abstract
The optimization of patients' treatment in the intensive care unit (ICU) needs a lot of information and literature analysis. Many changes have been made in the last years to help evaluate sedated patients by scores to help take care of them. Patients were completely sedated and had continuous intravenous analgesia and neuromuscular blockades. These three drug classes were the main drugs used for intubated patients in the ICU. During these last 20 years, ICU management went from fully sedated to awake, calm, and nonagitated patients, using less sedatives and choosing other drugs to decrease the risks of delirium during or after the ICU stay. Thus, the usefulness of these three drug classes has been challenged. The analgesic drugs used were primarily opioids but the use of other drugs instead is increasing to lessen or wean the use of opioids. In severe acute respiratory distress syndrome patients, neuromuscular blocking agents have been used frequently to block spontaneous respiration for 48 hours or more; however, this has recently been abolished. Optimizing a patient's comfort during hemodynamic or respiratory extracorporeal support is essential to reduce toxicity and secondary complications.
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Affiliation(s)
- David De Bels
- Intensive Care Unit, Brugmann University Hospital, Brussels, Belgium
| | - Ibrahim Bousbiat
- Intensive Care Unit, Brugmann University Hospital, Brussels, Belgium
| | - Emily Perriens
- Intensive Care Unit, Brugmann University Hospital, Brussels, Belgium
| | - Sydney Blackman
- Intensive Care Unit, Brugmann University Hospital, Brussels, Belgium
| | - Patrick M Honoré
- Department of Intensive Care, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
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5
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Oh TK, Song IA. Trends in Mortality, Treatment, and Costs of Management of Acute Respiratory Distress Syndrome in South Korea: Analysis of Data between 2010 and 2019. Yonsei Med J 2022; 63:452-460. [PMID: 35512748 PMCID: PMC9086700 DOI: 10.3349/ymj.2022.63.5.452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/17/2022] [Accepted: 02/09/2022] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Despite recent advances in the understanding and management of acute respiratory distress syndrome (ARDS), trends in treatment, mortality, and healthcare costs following these advancements remain to be identified. In the present study, we aimed to investigate these trends using real-world data from a national cohort database in South Korea. MATERIALS AND METHODS Using the National Health Insurance Service database, we collected and analyzed data for critically ill adult patients with ARDS who were admitted to intensive care units in South Korea between 2010 and 2019. RESULTS The final analysis included 25431 patients with ARDS. The 30-, 90-, and 365-day mortality rates in 2010 were 43.8%, 56.5%, and 68.2%, respectively. These rates had gradually decreased to 36.6%, 50.2%, and 58.8%, respectively, by 2019. Extracorporeal membrane oxygenation support for patients with ARDS started in 2014 at a rate of 5.1% (118/2309), which gradually increased to 8.3% (213/2568) by 2019. The rate of neuromuscular blockade treatment gradually increased from 22.6% (626/2771) in 2010 to 30.9% (793/2568) in 2019. The renal replacement therapy rate gradually increased from 5.7% (157/2771) in 2010 to 12.0% (307/2568) in 2019. The mean total cost of hospitalization increased from 5986.7 USD in 2010 to 12336.4 USD in 2019. CONCLUSION Real-world data for 2010-2019 indicate that patients with ARDS in South Korea have experienced changes in mortality, treatment, and healthcare costs. Despite the increased financial burden, mortality among patients with ARDS has decreased due to advances in disease management.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
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de Campos Biazon TMP, Libardi CA, Junior JCB, Caruso FR, da Silva Destro TR, Molina NG, Borghi-Silva A, Mendes RG. The effect of passive mobilization associated with blood flow restriction and combined with electrical stimulation on cardiorespiratory safety, neuromuscular adaptations, physical function, and quality of life in comatose patients in an ICU: a randomized controlled clinical trial. Trials 2021; 22:969. [PMID: 34969405 PMCID: PMC8719392 DOI: 10.1186/s13063-021-05916-z] [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] [Received: 12/13/2020] [Accepted: 12/06/2021] [Indexed: 11/14/2022] Open
Abstract
Background Intensive care unit-acquired atrophy and weakness are associated with high mortality, a reduction in physical function, and quality of life. Passive mobilization (PM) and neuromuscular electrical stimulation were applied in comatose patients; however, evidence is inconclusive regarding atrophy and weakness prevention. Blood flow restriction (BFR) associated with PM (BFRp) or with electrical stimulation (BFRpE) was able to reduce atrophy and increase muscle mass in spinal cord-injured patients, respectively. Bulky venous return occurs after releasing BFR, which can cause unknown repercussions on the cardiovascular system. Hence, the aim of this study was to investigate the effect of BFRp and BFRpE on cardiovascular safety and applicability, neuromuscular adaptations, physical function, and quality of life in comatose patients in intensive care units (ICUs). Methods Thirty-nine patients will be assessed at baseline (T0–18 h of coma) and randomly assigned to the PM (control group), BFRp, or BFRpE groups. The training protocol will be applied in both legs alternately, twice a day with a 4-h interval until coma awake, death, or ICU discharge. Cardiovascular safety and applicability will be evaluated at the first training session (T1). At T0 and 12 h after the last session (T2), muscle thickness and quality will be assessed. Global muscle strength and physical function will be assessed 12 h after T2 and ICU and hospital discharge for those who wake up from coma. Six and 12 months after hospital discharge, physical function and quality of life will be re-assessed. Discussion In view of applicability, the data will be used to inform the design and sample size of a prospective trial to clarify the effect of BFRpE on preventing muscle atrophy and weakness and to exert the greatest beneficial effects on physical function and quality of life compared to BFRp in comatose patients in the ICU. Trial registration Universal Trial Number (UTN) Registry UTN U1111-1241-4344. Retrospectively registered on 2 October 2019. Brazilian Clinical Trials Registry (ReBec) RBR-2qpyxf. Retrospectively registered on 21 January 2020, http://ensaiosclinicos.gov.br/rg/RBR-2qpyxf/ Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05916-z.
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Affiliation(s)
- Thaís Marina Pires de Campos Biazon
- Cardiopulmonary Physical Therapy Laboratory, Department of Physical Therapy, Federal University of São Carlos, Rod. Washington Luiz, km 235 - SP 310, CEP 13565-905, São Carlos, Brazil
| | - Cleiton Augusto Libardi
- Laboratory of Neuromuscular Adaptations to Resistance Training, Department of Physical Education, Federal University of São Carlos, São Carlos, Brazil
| | - Jose Carlos Bonjorno Junior
- Department of Medicine, Federal University of São Carlos, São Carlos, Brazil.,Department of Anesthesiology and Intensive Care Unit at the Irmandade da Santa Casa de Misericórdia de São Carlos, São Carlos, Brazil
| | - Flávia Rossi Caruso
- Cardiopulmonary Physical Therapy Laboratory, Department of Physical Therapy, Federal University of São Carlos, Rod. Washington Luiz, km 235 - SP 310, CEP 13565-905, São Carlos, Brazil
| | - Tamara Rodrigues da Silva Destro
- Cardiopulmonary Physical Therapy Laboratory, Department of Physical Therapy, Federal University of São Carlos, Rod. Washington Luiz, km 235 - SP 310, CEP 13565-905, São Carlos, Brazil
| | - Naiara Garcia Molina
- Cardiopulmonary Physical Therapy Laboratory, Department of Physical Therapy, Federal University of São Carlos, Rod. Washington Luiz, km 235 - SP 310, CEP 13565-905, São Carlos, Brazil
| | - Audrey Borghi-Silva
- Cardiopulmonary Physical Therapy Laboratory, Department of Physical Therapy, Federal University of São Carlos, Rod. Washington Luiz, km 235 - SP 310, CEP 13565-905, São Carlos, Brazil
| | - Renata Gonçalves Mendes
- Cardiopulmonary Physical Therapy Laboratory, Department of Physical Therapy, Federal University of São Carlos, Rod. Washington Luiz, km 235 - SP 310, CEP 13565-905, São Carlos, Brazil.
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7
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Dianti J, Angriman F, Ferreyro BL, Sklar MC, Brochard L, Ferguson ND, Goligher EC. Association of Mortality with Neuromuscular Blockade Differs according to Baseline Diaphragm Thickness. Am J Respir Crit Care Med 2021; 202:1717-1720. [PMID: 32717150 DOI: 10.1164/rccm.202004-1157le] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Jose Dianti
- University of Toronto Toronto, Ontario, Canada.,University Health Network Toronto, Ontario, Canada
| | - Federico Angriman
- University of Toronto Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre Toronto, Ontario, Canada
| | - Bruno L Ferreyro
- University of Toronto Toronto, Ontario, Canada.,Sinai Health System and University Health Network Toronto, Ontario, Canada
| | | | - Laurent Brochard
- University of Toronto Toronto, Ontario, Canada.,St. Michael's Hospital Toronto, Ontario, Canada and
| | - Niall D Ferguson
- University of Toronto Toronto, Ontario, Canada.,University Health Network Toronto, Ontario, Canada.,Toronto General Hospital Research Institute Toronto, Ontario, Canada
| | - Ewan C Goligher
- University of Toronto Toronto, Ontario, Canada.,University Health Network Toronto, Ontario, Canada.,Toronto General Hospital Research Institute Toronto, Ontario, Canada
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8
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Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
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Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
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Abstract
Neuromuscular blocking agents (NMBAs) inhibit patient-initiated active breath and the risk of high tidal volumes and consequent high transpulmonary pressure swings, and minimize patient/ ventilator asynchrony in acute respiratory distress syndrome (ARDS). Minimization of volutrauma and ventilator-induced lung injury (VILI) results in a lower incidence of barotrauma, improved oxygenation and a decrease in circulating proinflammatory markers. Recent randomized clinical trials did not reveal harmful muscular effects during a short course of NMBAs. The use of NMBAs should be considered during the early phase of severe ARDS for patients to facilitate lung protective ventilation or prone positioning only after optimising mechanical ventilation and sedation. The use of NMBAs should be integrated in a global strategy including the reduction of tidal volume, the rational use of PEEP, prone positioning and the use of a ventilatory mode allowing spontaneous ventilation as soon as possible. Partial neuromuscular blockade should be evaluated in future trials.
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10
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Renew JR, Ratzlaff R, Hernandez-Torres V, Brull SJ, Prielipp RC. Neuromuscular blockade management in the critically Ill patient. J Intensive Care 2020; 8:37. [PMID: 32483489 PMCID: PMC7245849 DOI: 10.1186/s40560-020-00455-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/13/2020] [Indexed: 12/16/2022] Open
Abstract
Neuromuscular blocking agents (NMBAs) can be an effective modality to address challenges that arise daily in the intensive care unit (ICU). These medications are often used to optimize mechanical ventilation, facilitate endotracheal intubation, stop overt shivering during therapeutic hypothermia following cardiac arrest, and may have a role in the management of life-threatening conditions such as elevated intracranial pressure and status asthmaticus (when deep sedation fails or is not tolerated). However, current NMBA use has decreased during the last decade due to concerns of potential adverse effects such as venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, and even residual paralysis following cessation of NMBA use. It is therefore essential for clinicians to be familiar with evidence-based practices regarding appropriate NMBA use in order to select appropriate indications for their use and avoid complications. We believe that selecting the right NMBA, administering concomitant sedation and analgesic therapy, and using appropriate monitoring techniques mitigate these risks for critically ill patients. Therefore, we review the indications of NMBA use in the critical care setting and discuss the most appropriate use of NMBAs in the intensive care setting based on their structure, mechanism of action, side effects, and recognized clinical indications. Lastly, we highlight the available pharmacologic antagonists, strategies for sedation, newer neuromuscular monitoring techniques, and potential complications related to the use of NMBAs in the ICU setting.
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Affiliation(s)
- J Ross Renew
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Robert Ratzlaff
- 2Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL USA
| | - Vivian Hernandez-Torres
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Sorin J Brull
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA.,3Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN USA
| | - Richard C Prielipp
- 3Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN USA
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11
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Flower L, Puthucheary Z. Muscle wasting in the critically ill patient: how to minimise subsequent disability. Br J Hosp Med (Lond) 2020; 81:1-9. [PMID: 32339009 DOI: 10.12968/hmed.2020.0045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Muscle wasting in critically ill patients is the most common complication associated with critical care. It has significant effects on physical and psychological health, mortality and quality of life. It is most severe in the first few days of illness and in the most critically unwell patients, with muscle loss estimated to occur at 2-3% per day. This muscle loss is likely a result of a reduction in protein synthesis relative to muscle breakdown, resulting in altered protein homeostasis. The associated weakness is associated with in an increase in both short- and long-term mortality and morbidity, with these detrimental effects demonstrated up to 5 years post discharge. This article highlights the significant impact that muscle wasting has on critically ill patients' outcomes, how this can be reduced, and how this might change in the future.
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Affiliation(s)
- Luke Flower
- Department of Anaesthetics, University College Hospital, London, UK
| | - Zudin Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Adult Critical Care Unit, Royal London Hospital, London, UK
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12
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Co I, Hyzy RC. Rescue Neuromuscular Blockade in Acute Respiratory Distress Syndrome Should Be Flat Dose. Crit Care Med 2020; 48:591-593. [PMID: 32205607 DOI: 10.1097/ccm.0000000000004198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Ivan Co
- Both authors: Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
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Mefford B, Donaldson JC, Bissell BD. To Block or Not: Updates in Neuromuscular Blockade in Acute Respiratory Distress Syndrome. Ann Pharmacother 2020; 54:899-906. [DOI: 10.1177/1060028020910132] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective: To review and evaluate neuromuscular blocking agents (NMBAs) in critically ill patients with acute respiratory distress syndrome (ARDS). Data Sources: A literature search utilizing PubMed was performed (January 1991 to January 2020) using the following search terms: ( neuromuscular blocking agents OR neuromuscular blockade OR cisatracurium OR rocuronium OR vecuronium OR pancuronium OR atracurium) AND * acute respiratory distress syndrome OR acute lung injury). Publications in English were evaluated. Study Selection and Data Extraction: Relevant clinical studies in humans were considered. Data Synthesis: Although NMBAs have been used for decades in the setting of ARDS, questions regarding mortality benefit remain. Early NMBA, within 48 hours of lung injury, have been historically used in critically ill patients with ARDS to aid in increasing alveolar recruitment, improving patient-ventilator synchrony, and promoting oxygenation by the prevention of contraction of respiratory muscles. Until recently, the literature showed an improvement in 90-day adjusted mortality. However, recent literature has demonstrated the lack of a mortality benefit. The continued receipt of NMBAs, with no clear benefit, could potentially lead to increased costs, skin breakdown, corneal abrasions, venous thromboembolisms, intensive care unit acquired weakness, and awareness with inappropriate sedation. Relevance to Patient Care and Clinical Practice: This review aims at discussing the preferred NMBA based on mechanism of action and reviews specific clinical trial data for the use of NMBAs in ARDS, clinical implications of these trial data, complications for the use of NMBAs, and needed future directions. Conclusions: The mortality benefit of NMBAs in ARDS has contradicting evidence with potentially serious adverse effects and notable controversies.
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Abdelaal Ahmed Mahmoud A, Mahmoud HE, Mahran MA, Khaled M. Streptokinase Versus Unfractionated Heparin Nebulization in Patients With Severe Acute Respiratory Distress Syndrome (ARDS): A Randomized Controlled Trial With Observational Controls. J Cardiothorac Vasc Anesth 2020; 34:436-443. [DOI: 10.1053/j.jvca.2019.05.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/19/2019] [Accepted: 05/23/2019] [Indexed: 02/08/2023]
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Hua Y, Ou X, Li Q, Zhu T. Neuromuscular blockers in the acute respiratory distress syndrome: A meta-analysis. PLoS One 2020; 15:e0227664. [PMID: 31961896 PMCID: PMC6974254 DOI: 10.1371/journal.pone.0227664] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/24/2019] [Indexed: 02/05/2023] Open
Abstract
Background The effects of neuromuscular blocking agents (NMBAs) on adult patients with acute respiratory distress syndrome (ARDS) remain unclear. We performed a meta-analysis of randomized controlled trials (RCTs) to evaluate its effect on mortality. Methods We searched the Cochrane (Central) database, Medline, Embase, the Chinese Biomedical Literature Database (SinoMed), WanFang data and ClinicalTrials from inception to June 2019, with language restriction to English and Chinese. We included published RCTs and eligible clinical trials from ClinicalTrials.gov that compared NMBAs with placebo or usual treatment in adults with ARDS. We pooled data using random-effects models. The primary outcome was mortality. The secondary outcomes were the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FIO2), total positive end expiratory pressure (PEEP), plateau pressure (Pplat), days free of ventilator at day 28, barotrauma and ICU-acquired weakness. Results We included 6 RCTs (n = 1557). Compared with placebo or usual treatment, NMBAs were associated with lower 21 to 28-day mortality (RR 0.72, 95% CI 0.53–0.97, I2 = 59%). NMBAs significantly improved oxygenation (Pao2:Fio2 ratios) at 48 hours (MD 27.26 mm Hg, 95% CI 1.67, 52.84, I2 = 92%) and reduced the incidence of barotrauma (RR 0.55, 95% CI 0.35, 0.85, I2 = 0). However, NMBAs had no effect on oxygenation (Pao2:Fio2 ratios) (MD 18.41 mm Hg, 95% CI -0.33, 37.14, I2 = 72%) at 24 hours. We also found NMBAs did not affect total PEEP, plateau pressure, days free of ventilation at day 28 and ICU-acquired weakness. Conclusions In patients with moderate-to-severe ARDS, the administration of NMBAs could reduce 21 to 28-day mortality and barotrauma, and improve oxygenation at 48 hours, but have no significant effects on 90-day/ICU mortality, days free of ventilation at day 28 and the risk of ICU-acquired weakness. Further large-scale, high-quality RCTs are needed to confirm our findings. Registration: PROSPERO (ID: CRD 42019139656).
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Affiliation(s)
- Yusi Hua
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xiaofeng Ou
- Department of Critical Care, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Qian Li
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- * E-mail:
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Trung TN, Duoc NVT, Nhat LTH, Yen LM, Hao NV, Truong NT, Duong HTH, Thuy DB, Phong NT, Tan LV, Puthucheary ZA, Thwaites CL. Functional outcome and muscle wasting in adults with tetanus. Trans R Soc Trop Med Hyg 2019; 113:706-713. [PMID: 31340037 PMCID: PMC6836715 DOI: 10.1093/trstmh/trz055] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/13/2019] [Accepted: 06/04/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In many countries, in-hospital survival from tetanus is increasing, but long-term outcome is unknown. In high-income settings, critical illness is associated with muscle wasting and poor functional outcome, but there are few data from resource-limited settings. In this study we aimed to assess muscle wasting and long-term functional outcome in adults with tetanus. METHODS In a prospective observational study involving 80 adults with tetanus, sequential rectus femoris ultrasound measurements were made at admission, 7 days, 14 days and hospital discharge. Functional outcome was assessed at hospital discharge using the Timed Up and Go test, Clinical Frailty Score, Barthel Index and RAND 36-item Short Form Health Survey (SF-36) and 3 and 6 months after discharge using the SF-36 and Barthel Index. RESULTS Significant muscle wasting occurred between hospital admission and discharge (p<0.01), particularly in severe disease, where a median 23.49% (interquartile range 10.01-26.07) reduction in rectus femoris cross-sectional area occurred in those with severe (Ablett grades 3 and 4) disease. Muscle mass at discharge was related to objective and subjective measures of physical and emotional function at discharge and 3 and 6 months after discharge. In patients >70 y of age, functional recovery at 6 months was reduced compared with younger patients. Hospital-acquired infection and age were risk factors for muscle wasting. CONCLUSIONS Significant muscle wasting during hospitalization occurred in patients with tetanus, the extent of which correlates with functional outcome.
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Affiliation(s)
- Truong N Trung
- Hospital for Tropical Diseases, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Viet Nam
| | - Nguyen V T Duoc
- Hospital for Tropical Diseases, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Viet Nam
| | - Le T H Nhat
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Viet Nam
| | - Lam M Yen
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Viet Nam
| | - Nguyen V Hao
- Hospital for Tropical Diseases, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Viet Nam
- University of Medicine and Pharmacy, Hong Bang, Phuong 11, Quan 5, Ho Chi Minh City, Viet Nam
| | - Nguyen T Truong
- Hospital for Tropical Diseases, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Viet Nam
| | - Ha T H Duong
- Hospital for Tropical Diseases, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Viet Nam
| | - Duong B Thuy
- Hospital for Tropical Diseases, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Viet Nam
| | - Nguyen T Phong
- Hospital for Tropical Diseases, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Viet Nam
| | - Le V Tan
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Viet Nam
| | - Zudin A Puthucheary
- William Harvey Research Institute, Barts and London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Adult Critical Care Unit, Royal London Hospital, London, UK
| | - C Louise Thwaites
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, 764 Vo Van Kiet, Quan 5, Ho Chi Minh City, Viet Nam
- Centre for Tropical Medicine and Global Health, University of Oxford, Nuffield Department of Medicine Research Building, University of Oxford, Old Road Campus, Roosevelt Drive, Headington, Oxford OX3 7FZ, UK
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Batt J, Herridge MS, Dos Santos CC. From skeletal muscle weakness to functional outcomes following critical illness: a translational biology perspective. Thorax 2019; 74:1091-1098. [PMID: 31431489 DOI: 10.1136/thoraxjnl-2016-208312] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 06/25/2019] [Accepted: 07/02/2019] [Indexed: 12/23/2022]
Abstract
Intensive care unit acquired weakness (ICUAW) is now a well-known entity complicating critical illness. It increases mortality and in the critical illness survivor it is associated with physical disability, substantially increased health resource utilisation and healthcare costs. Skeletal muscle wasting is a key driver of ICUAW and physical functional outcomes in both the short and long term. To date, there is no intervention that can universally and consistently prevent muscle loss during critical illness, or enhance its recovery following intensive care unit discharge, to improve physical function. Clinical trials of early mobilisation or exercise training, or enhanced nutritional support have generated inconsistent results and we have no effective pharmacological interventions. This review will delineate our current understanding of the mechanisms underpinning the development and persistence of skeletal muscle loss and dysfunction in the critically ill individual, highlighting recent discoveries and clinical observations, and utilisation of this knowledge in the development of novel therapeutics.
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Affiliation(s)
- Jane Batt
- Keenan Research Center for Biomedical Science, St Michael's Hospital, Toronto, Ontario, Canada .,Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Claudia C Dos Santos
- Keenan Research Center for Biomedical Science, St Michael's Hospital, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Tezcan B, Turan S, Özgök A. Current Use of Neuromuscular Blocking Agents in Intensive Care Units. Turk J Anaesthesiol Reanim 2019; 47:273-281. [PMID: 31380507 DOI: 10.5152/tjar.2019.33269] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 10/08/2018] [Indexed: 11/22/2022] Open
Abstract
Neuromuscular blocking agents can be used for purposes such as eliminating ventilator-patient dyssynchrony, facilitating gas exchange by reducing intra-abdominal pressure and improving chest wall compliance, reducing risk of lung barotrauma, decreasing contribution of muscles to oxygen consumption by preventing shivering and limiting elevations in intracranial pressure caused by airway stimulation in patients supported with mechanical ventilation in intensive care units. Adult Respiratory Distress Syndrome (ARDS), status asthmaticus, increased intracranial pressure and therapeutic hypothermia following ventricular fibrillation-associated cardiac arrest are some of clinical conditions that can be sustained by neuromuscular blockade. Appropriate indication and clinical practice have gained importance considering side effects such as ICU-acquired weakness, masking seizure activity and longer durations of hospital and ICU stays. We mainly aimed to review the current literature regarding neuromuscular blockade in up-to-date clinical conditions such as improving oxygenation in early ARDS and preventing shivering in the therapeutic hypothermia along with summarising the clinical practice in adult ICU in this report.
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Affiliation(s)
- Büşra Tezcan
- Clinic of Anaesthesiology and Reanimation, Department of Intensive Care, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Sema Turan
- Clinic of Anaesthesiology and Reanimation, Department of Intensive Care, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Ayşegül Özgök
- Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
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Chhetri I, Hunt JEA, Mendis JR, Patterson SD, Puthucheary ZA, Montgomery HE, Creagh-Brown BC. Repetitive vascular occlusion stimulus (RVOS) versus standard care to prevent muscle wasting in critically ill patients (ROSProx):a study protocol for a pilot randomised controlled trial. Trials 2019; 20:456. [PMID: 31340849 PMCID: PMC6657179 DOI: 10.1186/s13063-019-3547-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 06/29/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Forty per cent of critically ill patients are affected by intensive care unit-acquired weakness (ICU-AW), to which skeletal muscle wasting makes a substantial contribution. This can impair outcomes in hospital, and can cause long-term physical disability after hospital discharge. No effective mitigating strategies have yet been identified. Application of a repetitive vascular occlusion stimulus (RVOS) a limb pressure cuff inducing brief repeated cycles of ischaemia and reperfusion, can limit disuse muscle atrophy in both healthy controls and bed-bound patients recovering from knee surgery. We wish to determine whether RVOS might be effective in mitigating against muscle wasting in the ICU. Given that RVOS can also improve vascular function in healthy controls, we also wish to assess such effects in the critically ill. We here describe a pilot study to assess whether RVOS application is safe, tolerable, feasible and acceptable for ICU patients. METHODS This is a randomised interventional feasibility trial. Thirty-two ventilated adult ICU patients with multiorgan failure will be recruited within 48 h of admission and randomised to either the intervention arm or the control arm. Intervention participants will receive RVOS twice daily (except only once on day 1) for up to 10 days or until ICU discharge. Serious adverse events and tolerability (pain score) will be recorded; feasibility of trial procedures will be assessed against pre-specified criteria and acceptability by semi-structured interview. Together with vascular function, muscle mass and quality will be assessed using ultrasound and measures of physical function at baseline, on days 6 and 11 of study enrolment, and at ICU and hospital discharge. Blood and urine biomarkers of muscle metabolism, vascular function, inflammation and DNA damage/repair mechanism will also be analysed. The Health questionnaire will be completed 3 months after hospital discharge. DISCUSSION If this study demonstrates feasibility, the derived data will be used to inform the design (and sample size) of an appropriately-powered prospective trial to clarify whether RVOS can help preserve muscle mass/improve vascular function in critically ill patients. TRIAL REGISTRATION ISRCTN Registry, ISRCTN44340629. Registered on 26 October 2017.
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Affiliation(s)
- Ismita Chhetri
- Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, GU2 7XX UK
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Julie E. A. Hunt
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Jeewaka R. Mendis
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | | | - Zudin A. Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Institute for Sport, Exercise and Health, University College London, London, UK
- Department of Medicine, Centre for Human Health and Performance, University College London, London, UK
- Intensive Care Unit, Royal Free London NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King’s College London, London,, UK
| | - Hugh E. Montgomery
- Institute for Sport, Exercise and Health, University College London, London, UK
- Department of Medicine, Centre for Human Health and Performance, University College London, London, UK
| | - Benedict C. Creagh-Brown
- Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, GU2 7XX UK
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, UK
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Moss M, Huang DT, Brower RG, Ferguson ND, Ginde AA, Gong MN, Grissom CK, Gundel S, Hayden D, Hite RD, Hou PC, Hough CL, Iwashyna TJ, Khan A, Liu KD, Talmor D, Thompson BT, Ulysse CA, Yealy DM, Angus DC. Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome. N Engl J Med 2019; 380:1997-2008. [PMID: 31112383 PMCID: PMC6741345 DOI: 10.1056/nejmoa1901686] [Citation(s) in RCA: 496] [Impact Index Per Article: 99.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The benefits of early continuous neuromuscular blockade in patients with acute respiratory distress syndrome (ARDS) who are receiving mechanical ventilation remain unclear. METHODS We randomly assigned patients with moderate-to-severe ARDS (defined by a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen of <150 mm Hg with a positive end-expiratory pressure [PEEP] of ≥8 cm of water) to a 48-hour continuous infusion of cisatracurium with concomitant deep sedation (intervention group) or to a usual-care approach without routine neuromuscular blockade and with lighter sedation targets (control group). The same mechanical-ventilation strategies were used in both groups, including a strategy involving a high PEEP. The primary end point was in-hospital death from any cause at 90 days. RESULTS The trial was stopped at the second interim analysis for futility. We enrolled 1006 patients early after the onset of moderate-to-severe ARDS (median, 7.6 hours after onset). During the first 48 hours after randomization, 488 of the 501 patients (97.4%) in the intervention group started a continuous infusion of cisatracurium (median duration of infusion, 47.8 hours; median dose, 1807 mg), and 86 of the 505 patients (17.0%) in the control group received a neuromuscular blocking agent (median dose, 38 mg). At 90 days, 213 patients (42.5%) in the intervention group and 216 (42.8%) in the control group had died before hospital discharge (between-group difference, -0.3 percentage points; 95% confidence interval, -6.4 to 5.9; P = 0.93). While in the hospital, patients in the intervention group were less physically active and had more adverse cardiovascular events than patients in the control group. There were no consistent between-group differences in end points assessed at 3, 6, and 12 months. CONCLUSIONS Among patients with moderate-to-severe ARDS who were treated with a strategy involving a high PEEP, there was no significant difference in mortality at 90 days between patients who received an early and continuous cisatracurium infusion and those who were treated with a usual-care approach with lighter sedation targets. (Funded by the National Heart, Lung, and Blood Institute; ROSE ClinicalTrials.gov number, NCT02509078.).
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Affiliation(s)
- Marc Moss
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - David T Huang
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Roy G Brower
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Niall D Ferguson
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Adit A Ginde
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - M N Gong
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Colin K Grissom
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Stephanie Gundel
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Douglas Hayden
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - R Duncan Hite
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Peter C Hou
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Catherine L Hough
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Theodore J Iwashyna
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Akram Khan
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Kathleen D Liu
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Daniel Talmor
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - B Taylor Thompson
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Christine A Ulysse
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Donald M Yealy
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
| | - Derek C Angus
- The affiliations of the members of the writing committee are as follows: the Departments of Medicine (M.M.) and Emergency Medicine (A.A.G.), University of Colorado School of Medicine, Aurora; the Departments of Critical Care Medicine (D.T.H., D.C.A.) and Emergency Medicine (D.M.Y.), University of Pittsburgh School of Medicine, Pittsburgh; the Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (R.G.B.); the Interdepartmental Division of Critical Care Medicine, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto (N.D.F.); the Department of Medicine, Montefiore Hospital, New York (M.N.G.); the Department of Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City (C.K.G.); the Department of Medicine, University of Washington, Seattle (S.G., C.L.H.); the Biostatistics Center (D.H.), the Department of Medicine (B.T.T.), and the PETAL Network Clinical Coordinating Center (C.A.U.), Massachusetts General Hospital, the Department of Emergency Medicine, Division of Emergency Critical Care Medicine, Brigham and Women's Hospital (P.C.H.), and the Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center (D.T.) - all in Boston; the Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland (R.D.H.); the Department of Medicine, University of Michigan and Veterans Affairs Center for Clinical Research, Ann Arbor (T.J.I.); the Department of Medicine, Oregon Health and Science University, Portland (A.K.); and the Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco (K.D.L.)
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Zhu YP, Xia LX, Li GH. Management of early mobilization in intensive care units: a multicenter cross-sectional study. FRONTIERS OF NURSING 2018. [DOI: 10.1515/fon-2018-0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Objective
The aim of this study was to assess the management of early mobilization (EM) in Chinese intensive care units (ICUs).
Methods
This survey used a cross-sectional, observational design. A total of 65 tertiary and secondary hospitals were enrolled by convenience sampling and investigated using self-designed questionnaires.
Results
We identified 69 ICUs in Jiangsu, China (response rate: 94.2%). 74.2% (1,004/1,353) of the nurses and nursing managers from 65 ICUs reported mobility practice. For the mobility level, 98.1% (1,327) reported use of in-bed exercise, 5.7% (77) sitting on a side of bed, 21.7% (294) transfer to chair, and 2.4% (33) walking. The most frequently reported barriers to early mobility were unplanned extubation, nursing resource, and absence of physical therapist. Nurses’ educational backgrounds, nursing experience, the lack of nursing resources, absence of physician, and the weakness of patient were the factors that influenced ICU early rehabilitation (P<0.01).
Conclusions
Although implementation rates for EM in critically ill patients are high, the activity level is generally poor in most of the involved ICUs.
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Affiliation(s)
- Yan-Ping Zhu
- Intensive Care Units, Zhongda Hospital , Southeast University , Nanjing , Jiangsu 210009 , China
| | - Li-Xia Xia
- Department of Nursing , Jiangsu Provincial Hospital , Nanjing , Jiangsu 210009 , China
| | - Guo-Hong Li
- Department of Nursing , Zhongda Hospital , Southeast University , Nanjing , Jiangsu 210009 , China
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Barmparas G, Dhillon NK, Tatum JM, Patel K, Thomsen GM, Mason R, Margulies DR, Ley EJ. Extended neuromuscular blockade in acute respiratory distress syndrome does not increase mortality. J Surg Res 2018; 231:434-440. [DOI: 10.1016/j.jss.2018.06.074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 06/04/2018] [Accepted: 06/20/2018] [Indexed: 12/15/2022]
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Tsai-Nguyen G, Modrykamien AM. Use of neuromuscular blocking agents in acute respiratory distress syndrome. Proc (Bayl Univ Med Cent) 2018; 31:177-179. [PMID: 29706811 DOI: 10.1080/08998280.2017.1416237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 11/03/2017] [Accepted: 11/07/2017] [Indexed: 12/29/2022] Open
Abstract
Acute respiratory distress syndrome is the result of an acute inflammatory response of the lungs, causing severe hypoxemia. A variety of therapeutic modalities have been extensively studied, with only a few demonstrating improvement in survival. Specifically, mechanical ventilation with use of low tidal volumes, prone positioning, and treatment with neuromuscular blocking agents have proven beneficial. This article focuses on the utilization of neuromuscular blocking agents in this entity. In particular, we briefly review the mechanism of action of neuromuscular blockades, the latest published evidence supporting their use in acute respiratory distress syndrome, and current recommendations for their utilization in clinical practice.
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Affiliation(s)
- G Tsai-Nguyen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
| | - Ariel M Modrykamien
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas
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Abstract
Although acute survival from sepsis has improved in recent years, a large fraction of sepsis survivors experience poor long-term outcomes. In particular, sepsis survivors have high rates of weakness, cognitive impairment, hospital readmission, and late death. To improve long-term outcomes, in-hospital care should focus on early, effective treatment of sepsis; minimization of delirium, distress, and immobility; and preparing patients for hospital discharge. In the posthospital setting, medical care should focus on addressing new disability and preventing medical deterioration, providing a sustained period out of the hospital to allow for recovery.
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Affiliation(s)
- Hallie C Prescott
- Department of Internal Medicine, University of Michigan, VA Center for Clinical Management Research, HSR&D Center of Innovation, North Campus Research Center, 2800 Plymouth Road, Building 16, 341E, Ann Arbor, MI 48109-2800, USA.
| | - Deena Kelly Costa
- Department of Systems, Populations & Leadership, School of Nursing, University of Michigan, 400 North Ingalls Street #4351, Ann Arbor, MI 48109-5482, USA
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25
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Review of Continuous Infusion Neuromuscular Blocking Agents in the Adult Intensive Care Unit. Crit Care Nurs Q 2017; 40:323-343. [PMID: 28834856 DOI: 10.1097/cnq.0000000000000171] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of continuous infusion neuromuscular blocking agents remains controversial. The clinical benefit of these medications may be overshadowed by concerns of propagating intensive care unit-acquired weakness, which may prolong mechanical ventilation and impair the inability to assess neurologic function or pain. Despite these risks, the use of neuromuscular blocking agents in the intensive care unit is indicated in numerous clinical situations. Understanding pharmacologic nuances and clinical roles of these agents will aid in facilitating safe use in a variety of acute disease processes. This article provides clinicians with information regarding pharmacologic differences, indication for use, adverse effects, recommended doses, ancillary care, and monitoring among agents used for continuous neuromuscular blockade.
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Abstract
Neuromuscular diseases are syndromic disorders that affect nerve, muscle, and/or neuromuscular junction. Knowledge about the management of these diseases is required for anesthesiologists, because these may frequently be encountered in the intensive care unit, operating room, and other settings. The challenges and advances in management for some of the neuromuscular diseases most commonly encountered in the operating room and neurointensive care unit are reviewed.
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Affiliation(s)
- Veronica Crespo
- Department of Anesthesiology, Duke University, Erwin Road, Durham, NC 27710, USA
| | - Michael L Luke James
- Department of Anesthesiology, Duke University, Erwin Road, Durham, NC 27710, USA; Department of Neurology, Duke University, Erwin Road, Durham, NC 27710, USA.
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deBacker J, Hart N, Fan E. Neuromuscular Blockade in the 21st Century Management of the Critically Ill Patient. Chest 2016; 151:697-706. [PMID: 27818334 DOI: 10.1016/j.chest.2016.10.040] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Neuromuscular blockings agents (NMBAs) have a controversial role in the ventilatory and medical management of critical illness. The clinical concern surrounding NMBA-induced complications stems from evidence presented in the 2002 clinical practice guidelines, but new evidence from subsequent randomized trials and studies provides a more optimistic outlook about the application of NMBAs in the ICU. Furthermore, changes in the delivery of critical care, such as protocolized care pathways, minimizing or interrupting sedation, increased monitoring techniques, and overall improvements in reducing immobility, have created a modern, 21st century ICU environment whereby NMBAs may be administered safely. In this article we start with a review of the mechanism of action, side effects, and pharmacology of commonly used NMBAs. We then address the rationale for NMBA use for an expanding number of indications (endotracheal intubation, acute respiratory distress syndrome, status asthmaticus, increased intracranial and intra-abdominal pressure, and therapeutic hypothermia after cardiac arrest), with an emphasis on NMBA use in facilitating lung-protective ventilation for respiratory failure. We end with an appraisal over the importance of monitoring depth of paralysis and the concerns of complications, such as prolonged skeletal muscle weakness. In the context of adequate sedation and analgesia, monitored NMBA use (continuous or bolus administration) can be considered for the small number of clinical indications in critically ill patients for which evidence currently exists.
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Affiliation(s)
- Julian deBacker
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH; Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada
| | - Nicholas Hart
- Lane Fox Respiratory Service, St. Thomas' Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada.
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29
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Neuromuscular Blocking Agents and Neuromuscular Dysfunction Acquired in Critical Illness. Crit Care Med 2016; 44:2070-2078. [DOI: 10.1097/ccm.0000000000001839] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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30
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Peñuelas O, Muriel A, Frutos-Vivar F, Fan E, Raymondos K, Rios F, Nin N, Thille AW, González M, Villagomez AJ, Davies AR, Du B, Maggiore SM, Matamis D, Abroug F, Moreno RP, Kuiper MA, Anzueto A, Ferguson ND, Esteban A. Prediction and Outcome of Intensive Care Unit-Acquired Paresis. J Intensive Care Med 2016; 33:16-28. [PMID: 27080128 DOI: 10.1177/0885066616643529] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Intensive care unit-acquired paresis (ICUAP) is associated with poor outcomes. Our objective was to evaluate predictors for ICUAP and the short-term outcomes associated with this condition. METHODS A secondary analysis of a prospective study including 4157 mechanically ventilated adults in 494 intensive care units from 39 countries. After sedative interruption, patients were screened for ICUAP daily, which was defined as the presence of symmetric and flaccid quadriparesis associated with decreased or absent deep tendon reflexes. A multinomial logistic regression was used to create a predictive model for ICUAP. Propensity score matching was used to estimate the relationship between ICUAP and short-term outcomes (ie, weaning failure and intensive care unit [ICU] mortality). RESULTS Overall, 114 (3%) patients had ICUAP. Variables associated with ICUAP were duration of mechanical ventilation (relative risk ratio [RRR] per day, 1.10; 95% confidence interval [CI] 1.08-1.12), steroid therapy (RRR 1.8; 95% CI, 1.2-2.8), insulin therapy (RRR 1.8; 95% CI 1.2-2.7), sepsis (RRR 1.9; 95% CI: 1.2 to 2.9), acute renal failure (RRR 2.2; 95% CI 1.5-3.3), and hematological failure (RRR 1.9; 95% CI: 1.2-2.9). Coefficients were used to generate a weighted scoring system to predict ICUAP. ICUAP was significantly associated with both weaning failure (paired rate difference of 22.1%; 95% CI 9.8-31.6%) and ICU mortality (paired rate difference 10.5%; 95% CI 0.1-24.0%). CONCLUSIONS Intensive care unit-acquired paresis is relatively uncommon but is significantly associated with weaning failure and ICU mortality. We constructed a weighted scoring system, with good discrimination, to predict ICUAP in mechanically ventilated patients at the time of awakening.
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Affiliation(s)
- Oscar Peñuelas
- 1 Hospital Universitario de Getafe & Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain
| | - Alfonso Muriel
- 2 Unidad de Bioestadística Clinica Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigaciones Sanitarias (IRYCIS) & Centro de Investigación en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Fernando Frutos-Vivar
- 1 Hospital Universitario de Getafe & Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain
| | - Eddy Fan
- 3 Interdepartmental Division of Critical Care Medicine, and Departments of Medicine & Physiology, University of Toronto, Canada
| | | | - Fernando Rios
- 5 Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | - Nicolás Nin
- 6 Hospital Universitario de Montevideo, Uruguay
| | | | - Marco González
- 8 Clínica Medellín & Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Asisclo J Villagomez
- 9 Hospital Regional 1° de Octubre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE), México DF, México
| | - Andrew R Davies
- 10 Alfred Hospital & Monash University, Melbourne, Australia
| | - Bin Du
- 11 Peking Union Medical College Hospital, Beijing, Popular Republic of China
| | - Salvatore M Maggiore
- 12 Policlinico "Agostino Gemelli", Università Cattolica Del Sacro Cuore, Roma, Italy
| | | | - Fekri Abroug
- 14 Hospital Fattouma Bourguina, Monastir, Tunisia
| | - Rui P Moreno
- 15 Hospital de São José, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | | | - Antonio Anzueto
- 17 South Texas Veterans Health Care System and University of Texas Health Science Center, San Antonio, Texas
| | - Niall D Ferguson
- 3 Interdepartmental Division of Critical Care Medicine, and Departments of Medicine & Physiology, University of Toronto, Canada
| | - Andrés Esteban
- 1 Hospital Universitario de Getafe & Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain
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Ferguson ND, Thompson BT. Prone positioning and neuromuscular blocking agents are part of standard care in severe ARDS patients: no. Intensive Care Med 2015; 41:2198-200. [PMID: 26399891 DOI: 10.1007/s00134-015-4043-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 08/26/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Department of Physiology, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Valls-Matarín J, del Cotillo-Fuente M, Grané-Mascarell N, Quintana S. [Variation of muscle mass and weight in critical patient]. ENFERMERIA INTENSIVA 2015; 26:86-91. [PMID: 26165624 DOI: 10.1016/j.enfi.2015.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 04/22/2015] [Accepted: 05/13/2015] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Quantify the muscle mass and body weight variation in critically ill patients and to identify associated factors. METHOD A descriptive follow-up study. Data for demographic variables, body weight, fluid balance, daily kilocalories, the amount of sedation and muscle relaxants received and motor physiotherapy applied were collected. Three consecutive measurements were performed in the brachial biceps and quadriceps rectus by using ultrasound, upon admission and every 5 days until discharge. RESULTS 68 patients were included. Average age was of 73.5 [57-78,5] years. The median length of stay was 9.5 [5.5 -15] days. The median 16 (SD=5.7) daily kilocalories per kg/weight, 91.2% received sedation, 44.1% received muscle relaxants and 20% received physiotherapy. The patients presented a muscle wasting of 4.9 (SD=3.9)mm, p <.001 in the brachial biceps and 5.6 (SD=4.8)mm, p <.001 in the quadriceps rectus. Regression analysis selected the length of stay and the muscle relaxants are the most influential variables in the brachial biceps muscle wasting (R2=0.4), and length of stay as the most influential in the quadriceps rectus muscle wasting (R2=0.3). Patient's mean body weight on admission was of 81.1 (SD=15)kg and 81.2 (SD=14.2)kg on discharge, p=.95. CONCLUSIONS The critically ill patient presents a significant muscle waste related with the length of stay and the treatment received with muscle relaxants. Patients are being discharged with a similar body weight to which they were admitted but with a significant reduction of muscle mass.
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Affiliation(s)
- J Valls-Matarín
- Unidad de Cuidados Intensivos, Hospital Universitario Mútua Terrassa Tarrasa, Barcelona, España.
| | - M del Cotillo-Fuente
- Unidad de Cuidados Intensivos, Hospital Universitario Mútua Terrassa Tarrasa, Barcelona, España
| | - N Grané-Mascarell
- Unidad de Cuidados Intensivos, Hospital Universitario Mútua Terrassa Tarrasa, Barcelona, España
| | - S Quintana
- Unidad de Cuidados Intensivos, Hospital Universitario Mútua Terrassa Tarrasa, Barcelona, España
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Files DC, Sanchez MA, Morris PE. A conceptual framework: the early and late phases of skeletal muscle dysfunction in the acute respiratory distress syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:266. [PMID: 26134116 PMCID: PMC4488983 DOI: 10.1186/s13054-015-0979-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Patients with acute respiratory distress syndrome (ARDS) often develop severe diaphragmatic and limb skeletal muscle dysfunction. Impaired muscle function in ARDS is associated with increased mortality, increased duration of mechanical ventilation, and functional disability in survivors. In this review, we propose that muscle dysfunction in ARDS can be categorized into an early and a late phase. These early and late phases are based on the timing in relationship to lung injury and the underlying mechanisms. The early phase occurs temporally with the onset of lung injury, is driven by inflammation and disuse, and is marked predominantly by muscle atrophy from increased protein degradation. The ubiquitin-proteasome, autophagy, and calpain-caspase pathways have all been implicated in early-phase muscle dysfunction. Late-phase muscle weakness persists in many patients despite resolution of lung injury and cessation of ongoing acute inflammation-driven muscle atrophy. The clinical characteristics and mechanisms underlying late-phase muscle dysfunction do not involve the massive protein degradation and atrophy of the early phase and may reflect a failure of the musculoskeletal system to regain homeostatic balance. Owing to these underlying mechanistic differences, therapeutic interventions for treating muscle dysfunction in ARDS may differ during the early and late phases. Here, we review clinical and translational investigations of muscle dysfunction in ARDS, placing them in the conceptual framework of the early and late phases. We hypothesize that this conceptual model will aid in the design of future mechanistic and clinical investigations of the skeletal muscle system in ARDS and other critical illnesses.
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Affiliation(s)
- D Clark Files
- Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA. .,Critical Illness Injury and Recovery Research Center Chadwick Miller MD Department of Emergency Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Michael A Sanchez
- Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Peter E Morris
- Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.,Critical Illness Injury and Recovery Research Center Chadwick Miller MD Department of Emergency Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
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Friedrich O, Reid MB, Van den Berghe G, Vanhorebeek I, Hermans G, Rich MM, Larsson L. The Sick and the Weak: Neuropathies/Myopathies in the Critically Ill. Physiol Rev 2015; 95:1025-109. [PMID: 26133937 PMCID: PMC4491544 DOI: 10.1152/physrev.00028.2014] [Citation(s) in RCA: 216] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Critical illness polyneuropathies (CIP) and myopathies (CIM) are common complications of critical illness. Several weakness syndromes are summarized under the term intensive care unit-acquired weakness (ICUAW). We propose a classification of different ICUAW forms (CIM, CIP, sepsis-induced, steroid-denervation myopathy) and pathophysiological mechanisms from clinical and animal model data. Triggers include sepsis, mechanical ventilation, muscle unloading, steroid treatment, or denervation. Some ICUAW forms require stringent diagnostic features; CIM is marked by membrane hypoexcitability, severe atrophy, preferential myosin loss, ultrastructural alterations, and inadequate autophagy activation while myopathies in pure sepsis do not reproduce marked myosin loss. Reduced membrane excitability results from depolarization and ion channel dysfunction. Mitochondrial dysfunction contributes to energy-dependent processes. Ubiquitin proteasome and calpain activation trigger muscle proteolysis and atrophy while protein synthesis is impaired. Myosin loss is more pronounced than actin loss in CIM. Protein quality control is altered by inadequate autophagy. Ca(2+) dysregulation is present through altered Ca(2+) homeostasis. We highlight clinical hallmarks, trigger factors, and potential mechanisms from human studies and animal models that allow separation of risk factors that may trigger distinct mechanisms contributing to weakness. During critical illness, altered inflammatory (cytokines) and metabolic pathways deteriorate muscle function. ICUAW prevention/treatment is limited, e.g., tight glycemic control, delaying nutrition, and early mobilization. Future challenges include identification of primary/secondary events during the time course of critical illness, the interplay between membrane excitability, bioenergetic failure and differential proteolysis, and finding new therapeutic targets by help of tailored animal models.
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Affiliation(s)
- O Friedrich
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - M B Reid
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - G Van den Berghe
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - I Vanhorebeek
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - G Hermans
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - M M Rich
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
| | - L Larsson
- Institute of Medical Biotechnology, Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany; College of Health and Human Performance, University of Florida, Gainesville, Florida; Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium; Department of Neuroscience, Cell Biology and Physiology, Wright State University, Dayton, Ohio; and Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
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Parry SM, Puthucheary ZA. The impact of extended bed rest on the musculoskeletal system in the critical care environment. EXTREME PHYSIOLOGY & MEDICINE 2015; 4:16. [PMID: 26457181 PMCID: PMC4600281 DOI: 10.1186/s13728-015-0036-7] [Citation(s) in RCA: 160] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 09/30/2015] [Indexed: 04/14/2023]
Abstract
Prolonged immobility is harmful with rapid reductions in muscle mass, bone mineral density and impairment in other body systems evident within the first week of bed rest which is further exacerbated in individuals with critical illness. Our understanding of the aetiology and secondary consequences of prolonged immobilization in the critically ill is improving with recent and ongoing research to establish the cause, effect, and best treatment options. This review aims to describe the current literature on bed rest models for examining immobilization-induced changes in the musculoskeletal system and pathophysiology of immobilisation in critical illness including examination of intracellular signalling processes involved. Finally, the review examines the current barriers to early activity and mobilization and potential rehabilitation strategies, which are being, investigated which may reverse the effects of prolonged bed rest. Addressing the deleterious effects of immobilization is a major step in treatment and prevention of the public health issue, that is, critical illness survivorship.
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Affiliation(s)
- Selina M. Parry
- />Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Level 7 Alan Gilbert Building, Parkville, Melbourne, VIC 3010 Australia
| | - Zudin A. Puthucheary
- />Division of Respiratory and Critical Care Medicine, National University Health System, Singapore, Singapore
- />Institute of Health and Human Performance, University College London, London, UK
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Wright BJ. Lung-protective Ventilation Strategies and Adjunctive Treatments for the Emergency Medicine Patient with Acute Respiratory Failure. Emerg Med Clin North Am 2014; 32:871-87. [DOI: 10.1016/j.emc.2014.07.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Fan E, Dowdy DW, Colantuoni E, Mendez-Tellez PA, Sevransky JE, Shanholtz C, Himmelfarb CRD, Desai SV, Ciesla N, Herridge MS, Pronovost PJ, Needham DM. Physical complications in acute lung injury survivors: a two-year longitudinal prospective study. Crit Care Med 2014; 42:849-59. [PMID: 24247473 DOI: 10.1097/ccm.0000000000000040] [Citation(s) in RCA: 399] [Impact Index Per Article: 39.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Survivors of severe critical illness frequently develop substantial and persistent physical complications, including muscle weakness, impaired physical function, and decreased health-related quality of life. Our objective was to determine the longitudinal epidemiology of muscle weakness, physical function, and health-related quality of life and their associations with critical illness and ICU exposures. DESIGN A multisite prospective study with longitudinal follow-up at 3, 6, 12, and 24 months after acute lung injury. SETTING Thirteen ICUs from four academic teaching hospitals. PATIENTS Two hundred twenty-two survivors of acute lung injury. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS At each time point, patients underwent standardized clinical evaluations of extremity, hand grip, and respiratory muscle strength; anthropometrics (height, weight, mid-arm circumference, and triceps skin fold thickness); 6-minute walk distance, and the Medical Outcomes Short-Form 36 health-related quality of life survey. During their hospitalization, survivors also had detailed daily evaluation of critical illness and related treatment variables. Over one third of survivors had objective evidence of muscle weakness at hospital discharge, with most improving within 12 months. This weakness was associated with substantial impairments in physical function and health-related quality of life that persisted at 24 months. The duration of bed rest during critical illness was consistently associated with weakness throughout 24-month follow-up. The cumulative dose of systematic corticosteroids and use of neuromuscular blockers in the ICU were not associated with weakness. CONCLUSIONS Muscle weakness is common after acute lung injury, usually recovering within 12 months. This weakness is associated with substantial impairments in physical function and health-related quality of life that continue beyond 24 months. These results provide valuable prognostic information regarding physical recovery after acute lung injury. Evidence-based methods to reduce the duration of bed rest during critical illness may be important for improving these long-term impairments.
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Affiliation(s)
- Eddy Fan
- 1Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. 2Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, MD. 3Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. 4Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. 5Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. 6Division of Pulmonary, Allergy, and Critical Care Medicine, Emory University School of Medicine, Atlanta, GA. 7Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore, MD. 8Johns Hopkins University School of Nursing, Baltimore, MD. 9Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. 10Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. 11Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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Early exercise rehabilitation of muscle weakness in acute respiratory failure patients. Exerc Sport Sci Rev 2014; 41:208-15. [PMID: 23873130 DOI: 10.1097/jes.0b013e3182a4e67c] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Acute respiratory failure patients experience significant muscle weakness, which contributes to prolonged hospitalization and functional impairments after hospital discharge. Based on our previous work, we hypothesize that an exercise intervention initiated early in the intensive care unit aimed at improving skeletal muscle strength could decrease hospital stay and attenuate the deconditioning and skeletal muscle weakness experienced by these patients.
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Needham DM, Dinglas VD, Morris PE, Jackson JC, Hough CL, Mendez-Tellez PA, Wozniak AW, Colantuoni E, Ely EW, Rice TW, Hopkins RO. Physical and cognitive performance of patients with acute lung injury 1 year after initial trophic versus full enteral feeding. EDEN trial follow-up. Am J Respir Crit Care Med 2013; 188:567-76. [PMID: 23805899 DOI: 10.1164/rccm.201304-0651oc] [Citation(s) in RCA: 191] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
RATIONALE We hypothesized that providing patients with acute lung injury two different protein/calorie nutritional strategies in the intensive care unit may affect longer-term physical and cognitive performance. OBJECTIVES To assess physical and cognitive performance 6 and 12 months after acute lung injury, and to evaluate the effect of trophic versus full enteral feeding, provided for the first 6 days of mechanical ventilation, on 6-minute-walk distance, cognitive impairment, and secondary outcomes. METHODS A prospective, longitudinal ancillary study of the ARDS Network EDEN trial evaluating 174 consecutive survivors from 5 of 12 centers. Blinded assessments of patients' arm anthropometrics, strength, pulmonary function, 6-minute-walk distance, and cognitive status (executive function, language, memory, verbal reasoning/concept formation, and attention) were performed. MEASUREMENTS AND MAIN RESULTS At 6 and 12 months, respectively, the mean (SD) percent predicted for 6-minute-walk distance was 64% (22%) and 66% (25%) (P = 0.011 for difference between assessments), and 36 and 25% of survivors had cognitive impairment (P = 0.001). Patients performed below predicted values for secondary physical tests with small improvement from 6 to 12 months. There was no significant effect of initial trophic versus full feeding for the first 6 days after randomization on survivors' percent predicted for 6-minute-walk distance, cognitive impairment status, and all secondary outcomes. CONCLUSIONS EDEN trial survivors performed below predicted values for physical and cognitive performance at 6 and 12 months, with some improvement over time. Initial trophic versus full enteral feeding for the first 6 days after randomization did not affect physical and cognitive performance.
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Affiliation(s)
- Dale M Needham
- Outcomes after Critical Illness and Surgery Group, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland 21205, USA.
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Needham DM, Dinglas VD, Bienvenu OJ, Colantuoni E, Wozniak AW, Rice TW, Hopkins RO. One year outcomes in patients with acute lung injury randomised to initial trophic or full enteral feeding: prospective follow-up of EDEN randomised trial. BMJ 2013; 346:f1532. [PMID: 23512759 PMCID: PMC3601941 DOI: 10.1136/bmj.f1532] [Citation(s) in RCA: 189] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate the effect of initial low energy permissive underfeeding ("trophic feeding") versus full energy enteral feeding ("full feeding") on physical function and secondary outcomes in patients with acute lung injury. DESIGN Prospective longitudinal follow-up evaluation of the NHLBI ARDS Clinical Trials Network's EDEN trial SETTING 41hospitals in the United States. PARTICIPANTS 525 patients with acute lung injury. INTERVENTIONS Randomised assignment to trophic or full feeding for up to six days; thereafter, all patients still receiving mechanical ventilation received full feeding. MEASUREMENTS Blinded assessment of the age and sex adjusted physical function domain of the SF-36 instrument at 12 months after acute lung injury. Secondary outcome measures included survival; physical, psychological, and cognitive functioning; quality of life; and employment status at six and 12 months. RESULTS After acute lung injury, patients had substantial physical, psychological, and cognitive impairments, reduced quality of life, and impaired return to work. Initial trophic versus full feeding did not affect mean SF-36 physical function at 12 months (55 (SD 33) v 55 (31), P=0.54), survival to 12 months (65% v 63%, P=0.63), or nearly all of the secondary outcomes. CONCLUSION In survivors of acute lung injury, there was no difference in physical function, survival, or multiple secondary outcomes at 6 and 12 month follow-up after initial trophic or full enteral feeding. TRIAL REGISTRATION NCT No 00719446.
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Affiliation(s)
- Dale M Needham
- Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, MD 21205, USA.
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Weber-Carstens S, Schneider J, Wollersheim T, Assmann A, Bierbrauer J, Marg A, Al Hasani H, Chadt A, Wenzel K, Koch S, Fielitz J, Kleber C, Faust K, Mai K, Spies CD, Luft FC, Boschmann M, Spranger J, Spuler S. Critical illness myopathy and GLUT4: significance of insulin and muscle contraction. Am J Respir Crit Care Med 2012; 187:387-96. [PMID: 23239154 DOI: 10.1164/rccm.201209-1649oc] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Critical illness myopathy (CIM) has no known cause and no treatment. Immobilization and impaired glucose metabolism are implicated. OBJECTIVES We assessed signal transduction in skeletal muscle of patients at risk for CIM. We also investigated the effects of evoked muscle contraction. METHODS In a prospective observational and interventional pilot study, we screened 874 mechanically ventilated patients with a sepsis-related organ-failure assessment score greater than or equal to 8 for 3 consecutive days in the first 5 days of intensive care unit stay. Thirty patients at risk for CIM underwent euglycemic-hyperinsulinemic clamp, muscle microdialysis studies, and muscle biopsies. Control subjects were healthy. In five additional patients at risk for CIM, we performed corresponding analyses after 12-day, daily, unilateral electrical muscle stimulation with the contralateral leg as control. MEASUREMENTS AND MAIN RESULTS We performed successive muscle biopsies and assessed systemic insulin sensitivity and signal transduction pathways of glucose utilization at the mRNA and protein level and glucose transporter-4 (GLUT4) localization in skeletal muscle tissue. Skeletal muscle GLUT4 was trapped at perinuclear spaces, most pronounced in patients with CIM, but resided at the sarcolemma in control subjects. Glucose metabolism was not stimulated during euglycemic-hyperinsulinergic clamp. Insulin signal transduction was competent up to p-Akt activation; however, p-adenosine monophosphate-activated protein kinase (p-AMPK) was not detectable in CIM muscle. Electrical muscle stimulation increased p-AMPK, repositioned GLUT4, locally improved glucose metabolism, and prevented type-2 fiber atrophy. CONCLUSIONS Insufficient GLUT4 translocation results in decreased glucose supply in patients with CIM. Failed AMPK activation is involved. Evoked muscle contraction may prevent muscle-specific AMPK failure, restore GLUT4 disposition, and diminish protein breakdown. Clinical trial registered with http://www.controlled-trials.com (registration number ISRCTN77569430).
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Affiliation(s)
- Steffen Weber-Carstens
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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Connolly B, Denehy L, Brett S, Elliott D, Hart N. Exercise rehabilitation following hospital discharge in survivors of critical illness: an integrative review. Crit Care 2012; 16:226. [PMID: 22713336 PMCID: PMC3580599 DOI: 10.1186/cc11219] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Although clinical trials have shown benefit from early rehabilitation within the ICU, rehabilitation of patients following critical illness is increasingly acknowledged as an area of clinical importance. However, despite recommendations from published guidelines for rehabilitation to continue following hospital discharge, there is limited evidence to underpin practice during this intermediate stage of recovery. Those patients with ICU-acquired weakness on discharge from the ICU are most likely to benefit from ongoing rehabilitation. Despite this, screening based on strength alone may fail to account for the associated level of physical functioning, which may not correlate with muscle strength, nor address non-physical complications of critical illness. The aim of this review was to consider which patients are likely to require rehabilitation following critical illness and to perform an integrative review of the available evidence of content and nature of exercise rehabilitation programmes for survivors of critical illness following hospital discharge. Literature databases and clinical trials registries were searched using appropriate terms and groups of terms. Inclusion criteria specified the reporting of rehabilitation programmes for patients following critical illness post-hospital discharge. Ten items, including data from published studies and protocols from trial registries, were included. Because of the variability in study methodology and inadequate level of detail of reported exercise prescription, at present there can be no clear recommendations for clinical practice from this review. As this area of clinical practice remains in its relative infancy, further evidence is required both to identify which patients are most likely to benefit and to determine the optimum content and format of exercise rehabilitation programmes for patients following critical illness post-hospital discharge.
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Affiliation(s)
- Bronwen Connolly
- Department of Asthma, Allergy and Respiratory Science, Division of Asthma, Allergy and Lung Biology, King's College London, London SE1 9RT, UK
- Guy's and St Thomas' NHS Foundation Trust and King's College London, National Institute of Health Research Comprehensive Biomedical Research Centre, London SE1 9RT, UK
| | - Linda Denehy
- Department of Physiotherapy, Melbourne School of Health Sciences, The University of Melbourne, Melbourne, 3010 Australia
| | - Stephen Brett
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Doug Elliott
- Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, Sydney, 2007 Australia
| | - Nicholas Hart
- Department of Asthma, Allergy and Respiratory Science, Division of Asthma, Allergy and Lung Biology, King's College London, London SE1 9RT, UK
- Guy's and St Thomas' NHS Foundation Trust and King's College London, National Institute of Health Research Comprehensive Biomedical Research Centre, London SE1 9RT, UK
- Lane Fox Respiratory Unit, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
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