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Liu K, Tronstad O, Flaws D, Churchill L, Jones AYM, Nakamura K, Fraser JF. From bedside to recovery: exercise therapy for prevention of post-intensive care syndrome. J Intensive Care 2024; 12:11. [PMID: 38424645 PMCID: PMC10902959 DOI: 10.1186/s40560-024-00724-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 02/17/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND As advancements in critical care medicine continue to improve Intensive Care Unit (ICU) survival rates, clinical and research attention is urgently shifting toward improving the quality of survival. Post-Intensive Care Syndrome (PICS) is a complex constellation of physical, cognitive, and mental dysfunctions that severely impact patients' lives after hospital discharge. This review provides a comprehensive and multi-dimensional summary of the current evidence and practice of exercise therapy (ET) during and after an ICU admission to prevent and manage the various domains of PICS. The review aims to elucidate the evidence of the mechanisms and effects of ET in ICU rehabilitation and highlight that suboptimal clinical and functional outcomes of ICU patients is a growing public health concern that needs to be urgently addressed. MAIN BODY This review commences with a brief overview of the current relationship between PICS and ET, describing the latest research on this topic. It subsequently summarises the use of ET in ICU, hospital wards, and post-hospital discharge, illuminating the problematic transition between these settings. The following chapters focus on the effects of ET on physical, cognitive, and mental function, detailing the multi-faceted biological and pathophysiological mechanisms of dysfunctions and the benefits of ET in all three domains. This is followed by a chapter focusing on co-interventions and how to maximise and enhance the effect of ET, outlining practical strategies for how to optimise the effectiveness of ET. The review next describes several emerging technologies that have been introduced/suggested to augment and support the provision of ET during and after ICU admission. Lastly, the review discusses future research directions. CONCLUSION PICS is a growing global healthcare concern. This review aims to guide clinicians, researchers, policymakers, and healthcare providers in utilising ET as a therapeutic and preventive measure for patients during and after an ICU admission to address this problem. An improved understanding of the effectiveness of ET and the clinical and research gaps that needs to be urgently addressed will greatly assist clinicians in their efforts to rehabilitate ICU survivors, improving patients' quality of survival and helping them return to their normal lives after hospital discharge.
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Affiliation(s)
- Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Road, Chermside, QLD, 4032, Australia.
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia.
- Non-Profit Organization ICU Collaboration Network (ICON), Tokyo, Japan.
| | - Oystein Tronstad
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Road, Chermside, QLD, 4032, Australia
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
- Physiotherapy Department, The Prince Charles Hospital, Brisbane, Australia
| | - Dylan Flaws
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Road, Chermside, QLD, 4032, Australia
- Metro North Mental Health, Caboolture Hospital, Caboolture, Australia
- School of Clinical Science, Queensland University of Technology, Brisbane, Australia
| | - Luke Churchill
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Road, Chermside, QLD, 4032, Australia
- Physiotherapy Department, The Prince Charles Hospital, Brisbane, Australia
- School of Health & Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Alice Y M Jones
- School of Health & Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Kensuke Nakamura
- Department of Critical Care Medicine, Yokohama City University Hospital, Kanagawa, Japan
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, 627 Rode Road, Chermside, QLD, 4032, Australia
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
- Queensland University of Technology, Brisbane, Australia
- St. Andrews War Memorial Hospital, Brisbane, Australia
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Kumar N. Advances in post intensive care unit care: A narrative review. World J Crit Care Med 2023; 12:254-263. [DOI: 10.5492/wjccm.v12.i5.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/29/2023] [Accepted: 11/08/2023] [Indexed: 12/07/2023] Open
Abstract
As the treatment options, modalities and technology have grown, mortality in intensive care unit (ICU) has been on the decline. More and more patients are being discharged to wards and in the care of their loved ones after prolonged treatment at times and sometimes in isolation. These survivors have a lower life expectancy and a poorer quality of life. They can have substantial familial financial implications and an economic impact on the healthcare system in terms of increased and continued utilisation of services, the so-called post intensive care syndrome (PICS). But it is not only the patient who is the sufferer. The mental health of the loved ones and family members may also be affected, which is termed as PICS-family. In this review, we shall be reviewing the definition, epidemiology, clinical features, diagnosis and evaluation, treatment and follow up of PICS. We shall also focus on measures to prevent, rehabilitate and understand the ICU stay from patients’ perspective on how to redesign the ICU, post ICU care needs for a better patient outcome.
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Affiliation(s)
- Nishant Kumar
- Department of Anaesthesiology and Critical Care, Lady Hardinge Medical College and Associated Hospitals, New Delhi 110001, India
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Rapolthy-Beck A, Fleming J, Turpin M, Sosnowski K, Dullaway S, White H. Efficacy of Early Enhanced Occupational Therapy in an Intensive Care Unit (EFFORT-ICU): A Single-Site Feasibility Trial. Am J Occup Ther 2023; 77:7706205110. [PMID: 38015492 DOI: 10.5014/ajot.2023.050230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
IMPORTANCE This research trial contributes to the evidence for occupational therapy service delivery in intensive care settings. OBJECTIVE To explore the feasibility of a trial to evaluate the impact of early enhanced occupational therapy on mechanically ventilated patients in intensive care. DESIGN Single-site assessor-blinded randomized controlled feasibility trial. SETTING Level 5 8-bed adult medical-surgical intensive care unit (ICU) at Logan Hospital, Brisbane, Australia. PARTICIPANTS Participants were 30 mechanically ventilated patients randomly allocated to two groups. OUTCOMES AND MEASURES We compared standard care with enhanced occupational therapy with outcomes measured at discharge from the ICU, hospital discharge, and 90 days post randomization. The primary outcome measure was the FIM®. Secondary outcomes included the Modified Barthel Index (MBI); Montreal Cognitive Assessment; grip strength, measured using a dynamometer; Hospital Anxiety and Depression Scale; and the 36-Item Short-Form Health Survey (Version 2). The intervention group received daily occupational therapy, including cognitive stimulation, upper limb retraining, and activities of daily living. Data were analyzed using independent groups t tests and effect sizes. RESULTS Measures and procedures were feasible. A significant difference was found between groups on FIM Motor score at 90 days with a large effect size (p = .05, d = 0.76), and MBI scores for the intervention group approached significance (p = .051) with a large effect size (d = 0.75) at 90 days. Further moderate to large effect sizes were obtained for the intervention group for cognitive status, functional ability, and quality of life. CONCLUSIONS AND RELEVANCE This trial demonstrated that occupational therapy is feasible and beneficial in the ICU. Criteria to progress to a full-scale randomized controlled trial were met. This study contributes to embedding ongoing consistency of practice and scope of service delivery for occupational therapy in this field. What This Article Adds: Occupational therapists should be considered core team members in the critical care-ICU, with funding to support ongoing service provision and optimization of patient outcomes based on effective and feasible service delivery.
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Affiliation(s)
- Andrea Rapolthy-Beck
- Andrea Rapolthy-Beck, MSc Neurorehabilitation, BScOccTher, BSc(Med)ExSc, is Senior Occupational Therapist, Occupational Therapy Department, Surgical Treatment and Rehabilitation Service, Herston Health Precinct, Queensland, Australia; Senior Occupational Therapist, Occupational Therapy Department, Logan Hospital, Meadowbrook, Queensland, Australia; and PhD Candidate, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia;
| | - Jennifer Fleming
- Jennifer Fleming, PhD, BOccThy (Hons), FOTARA, is Professor and Head, Occupational Therapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Merrill Turpin
- Merrill Turpin, PhD, BOccThy, GradDipCounsel, is Senior Lecturer, Occupational Therapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Kellie Sosnowski
- Kellie Sosnowski, MNursing(Hons), BNursing, GradCertHlthMgt, GradDipCriticalCare, is Nurse Unit Manager, Intensive Care Unit, Logan Hospital, Meadowbrook, Queensland, Australia
| | - Simone Dullaway
- Simone Dullaway, BAppSc (Occ Ther), is Senior Occupational Therapist, Chronic Disease Team, Metro South Health and Hospital Service, Queensland, Australia
| | - Hayden White
- Hayden White, PhD, MBBCH, FCP (SA), MMED (Wits), FCICM, FRACP, is Deputy Director, Intensive Care Unit, Logan Hospital, Meadowbrook, Queensland, Australia
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Joshi S, Prakash R, Arshad Z, Kohli M, Singh GP, Chauhan N. Neuropsychiatric Outcomes in Intensive Care Unit Survivors. Cureus 2023; 15:e40693. [PMID: 37485209 PMCID: PMC10358786 DOI: 10.7759/cureus.40693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2023] [Indexed: 07/25/2023] Open
Abstract
BACKGROUND Over the last two decades, there has been phenomenal advancement in critical care medicine and patient management. Many patients recover from life-threatening illnesses that they might not have survived a decade ago. Despite a decrease in mortality, these survivors endure long-lasting sequelae like physical, mental, and emotional symptoms. METHODS Patients after intensive care unit (ICU) discharge were assessed in a follow-up outpatient department (OPD) clinic for anxiety, stress, and depression. Patients were asked to fill out the questionnaires Depression, Anxiety and Stress Scale-21 (DASS-21) and Short Form-36 (SF-36) for assessment of health-related quality of life (HRQOL) at 4th, 6th, and 8th months after discharge. ICU data were recorded, including patients' demographics, severity of illness and length of stay, and duration of mechanical ventilation. Patients who failed to follow-up in OPD on designated dates were assessed telephonically. RESULTS Depression showed a positive, strong, and moderate correlation between length of stay and mechanical ventilation duration. A positive correlation was found between stress and length of stay and duration of mechanical ventilation. A positive strong correlation was found between anxiety and length of ICU stay, and a moderate positive correlation was found between anxiety and duration of mechanical ventilation. A weak correlation was found between age and neuropsychiatric outcomes. CONCLUSION The severity of depression, anxiety, and stress was significantly higher at four months compared to six months. Severity decreased with time. Prolonged ICU stay increased levels of anxiety, depression, and stress. HRQOL improved from four to six months.
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Affiliation(s)
- Shivam Joshi
- Department of Anesthesiology and Critical Care, King George's Medical University, Lucknow, IND
| | - Ravi Prakash
- Department of Anesthesiology and Critical Care, King George's Medical University, Lucknow, IND
| | - Zia Arshad
- Department of Anesthesiology and Critical Care, King George's Medical University, Lucknow, IND
| | - Monica Kohli
- Department of Anesthesiology and Critical Care, King George's Medical University, Lucknow, IND
| | - Gyan Prakash Singh
- Department of Anesthesiology and Critical Care, King George's Medical University, Lucknow, IND
| | - Neelam Chauhan
- Department of Anesthesiology and Critical Care, King George's Medical University, Lucknow, IND
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Johnson KR, Temeyer JP, Schulte PJ, Nydahl P, Philbrick KL, Karnatovskaia LV. Aloud real- time reading of intensive care unit diaries: A feasibility study. Intensive Crit Care Nurs 2023; 76:103400. [PMID: 36706496 DOI: 10.1016/j.iccn.2023.103400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 01/10/2023] [Accepted: 01/18/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Memories of frightening/delusional intensive care unit experiences are a major risk factor for subsequent psychiatric morbidity of critical illness survivors; factual memories are protective. Systematically providing factual information during initial memory consolidation could mitigate the emotional character of the formed memories. We explored feasibility and obtained stakeholder feedback of a novel approach to intensive care unit diaries whereby entries were read aloud to the patients right after they were written to facilitate systematic real time orientation and formation of factual memories. RESEARCH METHODOLOGY Prospective interventional pilot study involving reading diary entries aloud. We have also interviewed involved stakeholders for feedback and collected exploratory data on psychiatric symptoms from patients right after the intensive care stay. SETTING Various intensive care units in a single academic center. MAIN OUTCOME MEASURES Feasibility was defined as intervention delivery on ≥80% of days following patient recruitment. Content analysis was performed on stakeholder interview responses. Questionnaire data were compared for patients who received real-time reading to the historical cohort who did not. RESULTS Overall, 57% (17 of 30) of patients achieved the set feasibility threshold. Following protocol adjustment, we achieved 86% feasibility in the last subset of patients. Patients reported the intervention as comforting and appreciated the reorientation aspect. Nurses overwhelmingly liked the idea; most common concern was not knowing what to write. Some therapists were unsure whether reading entries aloud might overwhelm the patients. There were no significant differences in psychiatric symptoms when compared to the historic cohort. CONCLUSION We encountered several implementation obstacles; once these were addressed, we achieved set feasibility target for the last group of patients. Reading diary entries aloud was welcomed by stakeholders. Designing a trial to assess efficacy of the intervention on psychiatric outcomes appears warranted. IMPLICATIONS FOR CLINICAL PRACTICE There is no recommendation to change current practice as benefits of the intervention are unproven.
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Affiliation(s)
- Kimberly R Johnson
- Department of Pulmonary and Critical Care, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
| | - Joseph P Temeyer
- Department of Nursing, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Phillip J Schulte
- Department of Biostatistics, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Peter Nydahl
- Department of Anesthesia and Critical Care, Arnold-Heller-Str. 3, University Hospital Schleswig-Holstein, Kiel 24105, Germany
| | - Kemuel L Philbrick
- Department of Psychiatry and Psychology, 200 First St SW, Mayo Clinic, Rochester, MN 55905, USA
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6
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Jarman A, Chapman K, Vollam S, Stiger R, Williams M, Gustafson O. Investigating the impact of physical activity interventions on delirium outcomes in intensive care unit patients: A systematic review and meta-analysis. J Intensive Care Soc 2023; 24:85-95. [PMID: 36874288 PMCID: PMC9975810 DOI: 10.1177/17511437221103689] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background To investigate the impact of physical activity interventions, including early mobilisation, on delirium outcomes in critically ill patients. Methods Electronic database literature searches were conducted, and studies were selected based on pre-specified eligibility criteria. Cochrane Risk of Bias-2 and Risk Of Bias In Non-randomised Studies-of Interventions quality assessment tools were utilised. Grading of Recommendations, Assessment, Development and Evaluations was used to assess levels of evidence for delirium outcomes. The study was prospectively registered on PROSPERO (CRD42020210872). Results Twelve studies were included; ten randomised controlled trials one observational case-matched study and one before-after quality improvement study. Only five of the included randomised controlled trial studies were judged to be at low risk of bias, with all others, including both non-randomised controlled trials deemed to be at high or moderate risk. The pooled relative risk for incidence was 0.85 (0.62-1.17) which was not statistically significant in favour of physical activity interventions. Narrative synthesis for effect on duration of delirium found favour towards physical activity interventions reducing delirium duration with median differences ranging from 0 to 2 days in three comparative studies. Studies comparing varying intervention intensities showed positive outcomes in favour of greater intensity. Overall levels of evidence were low quality. Conclusions Currently there is insufficient evidence to recommend physical activity as a stand-alone intervention to reduce delirium in Intensive Care Units. Physical activity intervention intensity may impact on delirium outcomes, but a lack of high-quality studies limits the current evidence base.
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Affiliation(s)
- Annika Jarman
- Critical Care Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Oxford Allied Health Professions Research & Innovation Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Keeleigh Chapman
- Department of Sport, Health Sciences and Social Work, Oxford Brookes University, Oxford, UK
| | - Sarah Vollam
- Critical Care Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Oxford NIHR Biomedical Research Centre, Oxford, UK
| | - Robyn Stiger
- Department of Sport, Health Sciences and Social Work, Oxford Brookes University, Oxford, UK.,Centre for Movement, Occupational and Rehabilitation Sciences, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
| | - Mark Williams
- Department of Sport, Health Sciences and Social Work, Oxford Brookes University, Oxford, UK.,Centre for Movement, Occupational and Rehabilitation Sciences, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
| | - Owen Gustafson
- Oxford Allied Health Professions Research & Innovation Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Centre for Movement, Occupational and Rehabilitation Sciences, Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
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Martinez RH, Liu KD, Aldrich JM. Overview of the Medical Management of the Critically Ill Patient. Clin J Am Soc Nephrol 2022; 17:1805-1813. [PMID: 36400435 PMCID: PMC9718009 DOI: 10.2215/cjn.07130622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The medical management of the critically ill patient focuses predominantly on treatment of the underlying condition (e g, sepsis or respiratory failure). However, in the past decade, the importance of initiating early prophylactic treatment for complications arising from care in the intensive care unit setting has become increasingly apparent. As survival from critical illness has improved, there is an increased prevalence of postintensive care syndrome-defined as a decline in physical, cognitive, or psychologic function among survivors of critical illness. The Intensive Care Unit Liberation Bundle, a major initiative of the Society of Critical Care Medicine, is centered on facilitating the return to normal function as early as possible, with the intent of minimizing iatrogenic harm during necessary critical care. These concepts are universally applicable to patients seen by nephrologists in the intensive care unit and may have particular relevance for patients with kidney failure either on dialysis or after kidney transplant. In this article, we will briefly summarize some known organ-based consequences associated with critical illness, review the components of the ABCDEF bundle (the conceptual framework for Intensive Care Unit Liberation), highlight the role nephrologists can play in implementing and complying with the ABCDEF bundle, and briefly discuss areas for additional research.
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Affiliation(s)
- Rebecca H. Martinez
- Critical Care Medicine, Department of Anesthesia, University of California, San Francisco, California
| | - Kathleen D. Liu
- Critical Care Medicine, Department of Anesthesia, University of California, San Francisco, California
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
| | - J. Matthew Aldrich
- Critical Care Medicine, Department of Anesthesia, University of California, San Francisco, California
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Chiel LE, Winthrop ZA, Fynn-Thompson F, Midyat L. Extracorporeal membrane oxygenation and paracorporeal lung assist devices as a bridge to pediatric lung transplantation. Pediatr Transplant 2022; 26:e14289. [PMID: 35416395 DOI: 10.1111/petr.14289] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/31/2022] [Accepted: 04/03/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND "Bridging" is a term used to describe the implementation of various treatment modalities to improve waitlist survival while a patient awaits lung transplantation. ECMO and PLAD are technologies used to bridge patients to lung transplantation. ECMO and PLAD are cardiopulmonary support systems that help move blood forward while using an artificial membrane to remove CO2 from and add O2 to the blood. Recent studies showed that these technologies are increasingly effective in bridging patients to lung transplantation, especially with optimizing patient selection, implementing physical rehabilitation and ambulation goals, standardization of management decisions, and increasing staff experience, among other considerations. We review these technologies, their roles as bridges to pediatric lung transplantation, as well as indications, contraindications, complications, and mortality rates. CONCLUSION Finally, we discuss the existing knowledge gaps and areas for future research to improve patient outcomes and understanding of lung assist devices.
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Affiliation(s)
- Laura E Chiel
- Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Zachary A Winthrop
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Levent Midyat
- Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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LaBuzetta JN, Malhotra A, Zee PC, Maas MB. Optimizing Sleep and Circadian Health in the NeuroICU. Curr Treat Options Neurol 2022; 24:309-325. [PMID: 35855215 PMCID: PMC9283559 DOI: 10.1007/s11940-022-00724-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2022] [Indexed: 12/04/2022]
Abstract
Purpose of Review This article introduces fundamental concepts in circadian biology and the neuroscience of sleep, reviews recent studies characterizing circadian rhythm and sleep disruption among critically ill patients and potentially links to functional outcomes, and draws upon existing literature to propose therapeutic strategies to mitigate those harms. Particular attention is given to patients with critical neurologic conditions and the unique environment of the neuro-intensive care unit. Recent Findings Circadian rhythm disruption is widespread among critically ill patients and sleep time is reduced and abnormally fragmented. There is a strong association between the degree of arousal suppression observed at the bedside and the extent of circadian disruption at the system (e.g., melatonin concentration rhythms) and cellular levels (e.g., core clock gene transcription rhythms). There is a paucity of electrographically normal sleep, and rest-activity rhythms are severely disturbed. Common care interventions such as neurochecks introduce unique disruptions in neurologic patients. There are no pharmacologic interventions proven to normalize circadian rhythms or restore physiologically normal sleep. Instead, interventions are focused on reducing pharmacologic and environmental factors that perpetuate disruption. Summary The intensive care environment introduces numerous potent disruptors to sleep and circadian rhythms. Direct neurologic injury and neuro-monitoring practices likely compound those factors to further derange circadian and sleep functions. In the absence of direct interventions to induce normalized rhythms and sleep, current therapy depends upon normalizing external stimuli.
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Affiliation(s)
- Jamie Nicole LaBuzetta
- Department of Neurosciences, Division of Neurocritical Care, University of California, San Diego, San Diego, USA
| | - Atul Malhotra
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, San Diego, USA
| | - Phyllis C. Zee
- Department of Neurology, Division of Sleep Medicine, Northwestern University, Chicago, USA
| | - Matthew B. Maas
- Department of Neurology, Division of Neurocritical Care, Northwestern University, 626 N Michigan Ave, Chicago, IL 60611 USA
- Department of Anesthesiology, Section of Critical Care Medicine, Northwestern University, 626 N Michigan Ave, Chicago, IL 60611 USA
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10
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Kho ME, Rewa OG, Boyd JG, Choong K, Stewart GCH, Herridge MS. Outcomes of critically ill COVID-19 survivors and caregivers: a case study-centred narrative review. Can J Anaesth 2022; 69:630-643. [PMID: 35102495 PMCID: PMC8802985 DOI: 10.1007/s12630-022-02194-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 11/10/2021] [Accepted: 11/22/2021] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Critical illness is a transformative experience for both patients and their family members. For COVID-19 patients admitted to the intensive care unit (ICU), survival may be the start of a long road to recovery. Our knowledge of the post-ICU long-term sequelae of acute respiratory distress syndrome (ARDS) and severe acute respiratory syndrome (SARS) may inform our understanding and management of the long-term effects of COVID-19. SOURCE We identified international and Canadian epidemiologic data on ICU admissions for COVID-19, COVID-19 pathophysiology, emerging ICU practice patterns, early reports of long-term outcomes, and federal support programs for survivors and their families. Centred around an illustrating case study, we applied relevant literature from ARDS and SARS to contextualize knowledge within emerging COVID-19 research and extrapolate findings to future long-term outcomes. PRINCIPAL FINDINGS COVID-19 is a multisystem disease with unknown long-term morbidity and mortality. Its pathophysiology is distinct and unique from ARDS, SARS, and critical illness. Nevertheless, based on initial reports of critical care management for COVID-19 and the varied injurious supportive practices employed in the ICU, patients and families are at risk for post-intensive care syndrome. The distinct incremental risk of COVID-19 multiple organ dysfunction is unknown. The risk of mood disorders in family members may be further exacerbated by imposed isolation and stigma. CONCLUSION Emerging literature on COVID-19 outcomes suggests some similarities with those of ARDS/SARS and prolonged mechanical ventilation. The pathophysiology of COVID-19 is presented here in the context of early outcome data and to inform an agenda for longitudinal research for patients and families.
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Affiliation(s)
- Michelle E Kho
- School of Rehabilitation Science, Faculty of Health Science, McMaster University, Hamilton, ON, Canada.
- School of Rehabilitation Science, Institute of Applied Health Sciences, McMaster University, Room 403, 1400 Main Street West, Hamilton, ON, L8S 1C7, Canada.
| | - Oleksa G Rewa
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - J Gordon Boyd
- Centre for Neuroscience Studies, Kingston Health Sciences Centre, and Department of Critical Care, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Karen Choong
- Department of Pediatrics and the Department of Health Research Methods, Evidence, and Impact McMaster University, Hamilton, ON, Canada
| | | | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto and University Health Network, Toronto General Hospital, Toronto, ON, Canada
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11
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Everaerts S, Heyns A, Langer D, Beyens H, Hermans G, Troosters T, Gosselink R, Lorent N, Janssens W. COVID-19 recovery: benefits of multidisciplinary respiratory rehabilitation. BMJ Open Respir Res 2021; 8:8/1/e000837. [PMID: 34489236 PMCID: PMC8423511 DOI: 10.1136/bmjresp-2020-000837] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 07/11/2021] [Indexed: 11/08/2022] Open
Abstract
Many patients struggle with ongoing symptoms in different domains (physical, mental, cognitive) after hospitalisation for COVID-19, calling out for a multidisciplinary approach. An outpatient multidisciplinary rehabilitation programme, according to a respiratory rehabilitation strategy, was set up for adult patients who were able to attend group sessions during 12 weeks. Results of 22 adult patients with COVID-19, of which 15 had required intensive care, were analysed and some general impressions and challenges of rehabilitation in COVID-19 were reported. Impressive results on physical recovery were determined after 6 weeks and 3 months, with significant improvement of lung function, muscle force and exercise capacity variables. A positive evolution of mental and cognitive burden was present, although less pronounced than the physical recovery. These mental and cognitive consequences seem, next to musculoskeletal and medical complications, the most challenging aspect of rehabilitating patients with COVID-19. These real-world data show feasibility and efficiency of a multidisciplinary respiratory rehabilitation programme after moderate to severe COVID-19 disease.
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Affiliation(s)
- Stephanie Everaerts
- Department of Respiratory Diseases, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Arne Heyns
- Department of Physical and Rehabilitation Medicine, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Daniel Langer
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
| | - Hilde Beyens
- Department of Physical and Rehabilitation Medicine, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Greet Hermans
- Department of General Internal Medicine, Medical Intensive Care Unit, KU Leuven University Hospitals Leuven, Leuven, Belgium.,Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Begium
| | - Thierry Troosters
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
| | - Rik Gosselink
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
| | - Natalie Lorent
- Department of Respiratory Diseases, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Wim Janssens
- Department of Respiratory Diseases, KU Leuven University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Aging (CHROMETA)-BREATHE, KU Leuven, Leuven, Belgium
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Role of Non-Invasive Respiratory Supports in COVID-19 Acute Respiratory Failure Patients with Do Not Intubate Orders. J Clin Med 2021; 10:jcm10132783. [PMID: 34202895 PMCID: PMC8267931 DOI: 10.3390/jcm10132783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 12/19/2022] Open
Abstract
The current gold-standard treatment for COVID-19-related hypoxemic respiratory failure is invasive mechanical ventilation. However, do not intubate orders (DNI), prevent the use of this treatment in some cases. The aim of this study was to evaluate if non-invasive ventilatory supports can provide a good therapeutic alternative to invasive ventilation in patients with severe COVID-19 infection and a DNI. Data were collected from four centres in three European countries. Patients with severe COVID-19 infection were included. We emulated a hypothetical target trial in which outcomes were compared in patients with a DNI order treated exclusively by non-invasive respiratory support with patients who could be intubated if necessary. We set up a propensity score and an inverse probability of treatment weighting to remove confounding by indication. Four-hundred patients were included: 270 were eligible for intubation and 130 had a DNI order. The adjusted risk ratio for death among patients eligible for intubation was 0.81 (95% CI 0.46 to 1.42). The median length of stay in acute care for survivors was similar between groups (18 (10-31) vs. (19 (13-23.5); p = 0.76). The use of non-invasive respiratory support is a good compromise for patients with severe COVID-19 and a do not intubate order.
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13
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Nydahl P, McWilliams D, Weiler N, Borzikowsky C, Howroyd F, Brobeil A, Lindner M, von Haken R. Mobilization in the evening to prevent delirium: A pilot randomized trial. Nurs Crit Care 2021; 27:519-527. [PMID: 33946128 DOI: 10.1111/nicc.12638] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/08/2021] [Accepted: 04/10/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Delirium is a common complication in patients in Intensive Care Units (ICU). Interventions such as mobilization are effective in the prevention and treatment of delirium, although this is usually completed during the daytime. AIM The aim of this study was to assess the feasibility of mobilization in the evening to prevent and treat ICU patients from delirium by an additional mobility team over 2 weeks. METHODS The design was a pilot, multi-centre, randomized, controlled trial in four mixed ICUs over a period of 2 weeks. The mobility team consisted of trained nurses and physiotherapists. Patients in the intervention group were mobilized onto the edge of the bed or more between 21.00 and 23.00. Patients in the control group received usual care. The primary outcome parameter was the feasibility of the study, measured as recruitment rate, delivery rate, and safety. Secondary outcomes were duration and incidence of delirium, mortality, duration of mechanical ventilation (MV), and hospital length of stay for 28 days follow-up, and power calculation for a full trial. RESULTS Out of 185 patients present in the ICUs, 28.6% (n = 53) were eligible and could be recruited, of which 24.9% (n = 46, Intervention = 26, Control = 20) were included in the final analysis. In the intervention group, mobilization could be delivered in 75% (n = 54) of 72 possible occasions; mobilization-related safety events appeared in 16.7% (n = 9) without serious consequences. Secondary parameters were similar, with less delirium in the intervention group albeit not significant. With an association of Cramer's V = 0.237, a complete study reaching statistical significance would require at least 140 patients, last 6 weeks, and cost >30 000 €. CONCLUSIONS In a mixed ICU population, mobilization in the evening was feasible in one-quarter of patients with a low rate of safety events. Future trials seem to be feasible and worth conducting.
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Affiliation(s)
- Peter Nydahl
- Nursing Research, University Hospital Schleswig-Holstein, Kiel, Germany.,Department of Anaesthesiology and Critical Care Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - David McWilliams
- Centre for Care Excellence, University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Norbert Weiler
- Department of Anaesthesiology and Critical Care Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Christoph Borzikowsky
- Institute of Medical Informatics and Statistics, Kiel University, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Fiona Howroyd
- Therapy Services, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Matthias Lindner
- Department of Anaesthesiology and Critical Care Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Rebecca von Haken
- Department of Anaesthesiology, University Hospital Mannheim, Heidelberg, Germany
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Physical and Cognitive Training to Enhance Intensive Care Unit Survivors' Cognition: A Mapping Review. Rehabil Nurs 2021; 46:323-332. [PMID: 33833206 DOI: 10.1097/rnj.0000000000000325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to examine current literature regarding effects of physical or cognitive training and simultaneous (dual-task) physical and cognitive training on cognition in adults surviving an intensive care unit (ICU) stay. DESIGN Systematic mapping. METHODS A literature search was conducted to examine effects of physical and/or cognitive training on cognitive processes. RESULTS Few studies targeted adults surviving ICU. Independently, physical and cognitive interventions improved cognition in healthy older adults with and without cognitive impairment. Simultaneous interventions may improve executive function. Small sample size and heterogeneity of interventions limited the ability to make inferences. CONCLUSION Literature supports positive effects of single- and dual-task training on recovering cognition in adults. This training could benefit ICU survivors who need to regain cognitive function and prevent future decline. RELEVANCE TO PRACTICE With the growing number of ICU survivors experiencing cognitive deficits, it is essential to develop and test interventions that restore cognitive function in this understudied population.
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Mart MF, Williams Roberson S, Salas B, Pandharipande PP, Ely EW. Prevention and Management of Delirium in the Intensive Care Unit. Semin Respir Crit Care Med 2021; 42:112-126. [PMID: 32746469 PMCID: PMC7855536 DOI: 10.1055/s-0040-1710572] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality, longer lengths of stay, higher hospital costs, and cognitive impairment that persists long after hospital discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia. Precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives and adverse environmental conditions impairing vision, hearing, and sleep. Historically, antipsychotic medications were the mainstay of delirium treatment in the critically ill. Based on more recent literature, the current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation and their impact is not yet clear. Nonpharmacologic interventions thus remain the cornerstone of delirium management. This approach is summarized in the ABCDEF bundle (Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment). The implementation of this bundle reduces the odds of developing delirium and the chances of needing mechanical ventilation, yet there are challenges to its implementation. There is an urgent need for ongoing studies to more effectively mitigate risk factors and to better understand the pathobiology underlying ICU delirium so as to identify additional potential treatments. Further refinements of therapeutic options, from drugs to rehabilitation, are current areas ripe for study to improve the short- and long-term outcomes of critically ill patients with delirium.
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Affiliation(s)
- Matthew F. Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
| | - Shawniqua Williams Roberson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Bioengineering, Vanderbilt University, Nashville, Tennessee
| | - Barbara Salas
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Pratik P. Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Division of Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- VA Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee
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16
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Balczon R, Morrow KA, Leavesley S, Francis CM, Stevens TC, Agwaramgbo E, Williams C, Stevens RP, Langham G, Voth S, Cioffi EA, Weintraub SE, Stevens T. Cystatin C regulates the cytotoxicity of infection-induced endothelial-derived β-amyloid. FEBS Open Bio 2020; 10:2464-2477. [PMID: 33030263 PMCID: PMC7609779 DOI: 10.1002/2211-5463.12997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 08/25/2020] [Accepted: 10/05/2020] [Indexed: 02/06/2023] Open
Abstract
Infection of rat pulmonary microvascular endothelial cells with the bacterium Pseudomonas aeruginosa induces the production and release of cytotoxic oligomeric tau and beta amyloid (Aβ). Here, we characterized these cytotoxic amyloids. Cytotoxic behavior and oligomeric tau were partially resistant to digestion with proteinase K, but cytotoxicity was abolished by various denaturants including phenol, diethylpyrocarbonate (DEPC), and 1,1,1,3,3,3-hexafluoro-2-isopropanol (HFIP). Ultracentrifugation for 8 h at 150 000 g was required to remove cytotoxic activity from the supernatant. Ultracentrifugation, DEPC treatment, and immunodepletion using antibodies against Aβ also demonstrated that cytoprotective protein(s) are released from endothelial cells during P. aeruginosa infection. Mass spectrometry of endothelial cell culture media following P. aeruginosa infection allowed identification of multiple potential secreted modulators of Aβ, including cystatin C, gelsolin, and ApoJ/clusterin. Immunodepletion, co-immunoprecipitation, and ultracentrifugation determined that the cytoprotective factor released during infection of endothelial cells by P. aeruginosa is cystatin C, which appears to be in a complex with Aβ. Cytoprotective cystatin C may provide a novel therapeutic avenue for protection against the long-term consequences of infection with P. aeruginosa.
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Affiliation(s)
- Ron Balczon
- Department of Biochemistry and Molecular BiologyUniversity of South AlabamaMobileALUSA
- Center for Lung BiologyUniversity of South AlabamaMobileALUSA
| | - Kyle A. Morrow
- Department of Cell Biology and PhysiologyEdward Via College of Osteopathic MedicineMonroeLAUSA
| | - Silas Leavesley
- Center for Lung BiologyUniversity of South AlabamaMobileALUSA
- Department of Chemical and Biomedical EngineeringUniversity of South AlabamaMobileALUSA
| | - Christopher M. Francis
- Center for Lung BiologyUniversity of South AlabamaMobileALUSA
- Department of Physiology and Cell BiologyUniversity of South AlabamaMobileALUSA
| | - Trevor C. Stevens
- Center for Lung BiologyUniversity of South AlabamaMobileALUSA
- Department of Physiology and Cell BiologyUniversity of South AlabamaMobileALUSA
| | - Ezinne Agwaramgbo
- Department of Physiology and Cell BiologyUniversity of South AlabamaMobileALUSA
| | | | - Reece P. Stevens
- Center for Lung BiologyUniversity of South AlabamaMobileALUSA
- Department of Physiology and Cell BiologyUniversity of South AlabamaMobileALUSA
| | - Geri Langham
- Department of Physiology and Cell BiologyUniversity of South AlabamaMobileALUSA
| | - Sarah Voth
- Center for Lung BiologyUniversity of South AlabamaMobileALUSA
- Department of Physiology and Cell BiologyUniversity of South AlabamaMobileALUSA
| | - Eugene A. Cioffi
- Department of PharmacologyUniversity of South AlabamaMobileALUSA
| | - Susan E. Weintraub
- Department of Biochemistry and Structural Biology and Mass Spectrometry LaboratoryUniversity of Texas at San Antonio Health Sciences CenterTXUSA
| | - Troy Stevens
- Center for Lung BiologyUniversity of South AlabamaMobileALUSA
- Department of Physiology and Cell BiologyUniversity of South AlabamaMobileALUSA
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Honarmand K, Lalli RS, Priestap F, Chen JL, McIntyre CW, Owen AM, Slessarev M. Natural History of Cognitive Impairment in Critical Illness Survivors. A Systematic Review. Am J Respir Crit Care Med 2020; 202:193-201. [PMID: 32078780 PMCID: PMC7365360 DOI: 10.1164/rccm.201904-0816ci] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Long-term cognitive impairment is common among ICU survivors, but its natural history remains unclear. In this systematic review, we report the frequency of cognitive impairment in ICU survivors across various time points after ICU discharge that were extracted from 46 of the 3,350 screened records. Prior studies used a range of cognitive instruments, including subjective assessments (10 studies), single or screening cognitive test such as Mini-Mental State Examination or Trail Making Tests A and B (23 studies), and comprehensive cognitive batteries (26 studies). The mean prevalence of cognitive impairment was higher with objective rather than subjective assessments (54% [95% confidence interval (CI), 51–57%] vs. 35% [95% CI, 29–41%] at 3 months after ICU discharge) and when comprehensive cognitive batteries rather than Mini-Mental State Examination were used (ICU discharge: 61% [95% CI, 38–100%] vs. 36% [95% CI, 15–63%]; 12 months after ICU discharge: 43% [95% CI, 10–78%] vs. 18% [95% CI, 10–20%]). Patients with acute respiratory distress syndrome had higher prevalence of cognitive impairment than mixed ICU patients at ICU discharge (82% [95% CI, 78–86%] vs. 48% [95% CI, 44–52%]). Although some studies repeated tests at more than one time point, the time intervals between tests were arbitrary and dictated by operational limitations of individual studies or chosen cognitive instruments. In summary, the prevalence and temporal trajectory of ICU-related cognitive impairment varies depending on the type of cognitive instrument used and the etiology of critical illness. Future studies should use modern comprehensive batteries to better delineate the natural history of cognitive recovery across ICU patient subgroups and determine which acute illness and treatment factors are associated with better recovery trajectories.
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Affiliation(s)
| | | | | | | | | | - Adrian M Owen
- Brain and Mind Institute, and.,Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
| | - Marat Slessarev
- Department of Medicine.,Department of Medical Biophysics.,Brain and Mind Institute, and.,Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
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Söderberg A, Karlsson V, Ahlberg BM, Johansson A, Thelandersson A. From fear to fight: Patients experiences of early mobilization in intensive care. A qualitative interview study. Physiother Theory Pract 2020; 38:750-758. [PMID: 32787479 DOI: 10.1080/09593985.2020.1799460] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Early mobilization (EM) in intensive care is frequently used to prevent physical and psychological complications, with promising results. However, the patient´s perception of EM has been sparsely investigated. Purpose: To investigate the experience of EM in patients treated in intensive care. Method: Nineteen former patients who had been treated in intensive care were interviewed. The interviews were analyzed using qualitative, inductive content analysis. Results: The analysis resulted in three categories; 1) Facing the impossible - a too demanding situation; 2) Struggling successfully on the way back; and 3) Need of having dedicated supporters. Conclusion: A considerable variety of experiences of EM were described in this study, both negative and positive. Prominent features were that pleasant emotions and great physical effort occurred simultaneously and that interaction and cooperation with the caregivers was paramount. To regain independence was another prominent feature, with EM considered to be of great importance in the recovery process. Moving to an upright position and ambulating appears to be beneficial to both body and mind. EM should therefore be among the first priorities in intensive care. EM should be practiced with respect and support, while encouraging and challenging the patient to strive for independence.
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Affiliation(s)
- Annika Söderberg
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden.,Department of Physiotherapy, Skaraborgs Hospital Skövde, Skövde, Sweden
| | | | | | - Anita Johansson
- Research and Development Centre, Skaraborg Hospital Skövde, Skövde, Sweden
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19
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Kohler J, Borchers F, Endres M, Weiss B, Spies C, Emmrich JV. Cognitive Deficits Following Intensive Care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:627-634. [PMID: 31617485 DOI: 10.3238/arztebl.2019.0627] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 02/06/2019] [Accepted: 07/16/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Illnesses that necessitate intensive care can impair cognitive function severely over the long term, leaving patients less able to cope with the demands of everyday living and markedly lowering their quality of life. There has not yet been any comprehensive study of the cognitive sequelae of critical illness among non- surgical patients treated in intensive care. The purpose of this review is to present the available study findings on cognitive deficits in such patients, with particular at- tention to prevalence, types of deficit, clinical course, risk factors, prevention, and treatment. METHODS This review is based on pertinent publications retrieved by a selective search in MEDLINE. RESULTS The literature search yielded 3360 hits, among which there were 14 studies that met our inclusion criteria. 17-78% of patients had cognitive deficits after dis- charge from the intensive care unit; most had never had a cognitive deficit before. Cognitive impairment often persisted for up to several years after discharge (0.5 to 9 years) and tended to improve over time. The only definite risk factor is delirium. CONCLUSION Cognitive dysfunction is a common sequela of the treatment of non-surgical patients in intensive care units. It is a serious problem for the affected persons and an increasingly important socio-economic problem as well. The effective management of delirium is very important. General conclusions are hard to draw from the available data because of heterogeneous study designs, varying methods of measurement, and differences among patient cohorts. Further studies are needed so that study designs and clinical testing procedures can be standard- ized and effective measures for prevention and treatment can be identified.
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Affiliation(s)
- Joel Kohler
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin; Department of Anesthesiology and Operative Intensive Care Medicine at Campus Benjamin Franklin Charité-Universitätsmedizin Berlin
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20
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Williams CN, Hartman ME, Guilliams KP, Guerriero RM, Piantino JA, Bosworth CC, Leonard SS, Bradbury K, Wagner A, Hall TA. Postintensive Care Syndrome in Pediatric Critical Care Survivors: Therapeutic Options to Improve Outcomes After Acquired Brain Injury. Curr Treat Options Neurol 2019; 21:49. [PMID: 31559490 DOI: 10.1007/s11940-019-0586-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Children surviving the pediatric intensive care unit (PICU) with neurologic illness or injury have long-term morbidities in physical, cognitive, emotional, and social functioning termed postintensive care syndrome (PICS). In this article, we review acute and longitudinal management strategies available to combat PICS in children with acquired brain injury. RECENT FINDINGS Few intervention studies in this vulnerable population target PICS morbidities. Small studies show promise for both inpatient- and outpatient-initiated therapies, mainly focusing on a single domain of PICS and evaluating heterogeneous populations. While evaluating the effects of interventions on longitudinal PICS outcomes is in its infancy, longitudinal clinical programs targeting PICS are increasing. A multidisciplinary team with inpatient and outpatient presence is necessary to deliver the holistic integrated care required to address all domains of PICS in patients and families. While PICS is increasingly recognized as a chronic problem in PICU survivors with acquired brain injury, few interventions have targeted PICS morbidities. Research is needed to improve physical, cognitive, emotional, and social outcomes in survivors and their families.
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Affiliation(s)
- Cydni N Williams
- Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health and Science University, 707 SW Gaines St., CDRC-P, Portland, OR, 97239, USA.
- Department of Pediatrics, Division of Pediatric Critical Care, Oregon Health and Science University, Portland, OR, USA.
| | - Mary E Hartman
- Department of Pediatrics, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Kristin P Guilliams
- Department of Pediatrics, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA
- Department of Neurology, Division of Pediatric and Developmental Neurology, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Rejean M Guerriero
- Department of Neurology, Division of Pediatric and Developmental Neurology, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Juan A Piantino
- Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health and Science University, 707 SW Gaines St., CDRC-P, Portland, OR, 97239, USA
- Department of Pediatrics, Division of Pediatric Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Christopher C Bosworth
- Department of Psychology, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Skyler S Leonard
- Department of Pediatrics, Division of Pediatric Psychology, Oregon Health and Science University, Portland, OR, USA
| | - Kathryn Bradbury
- Department of Pediatrics, Division of Pediatric Psychology, Oregon Health and Science University, Portland, OR, USA
| | - Amanda Wagner
- Department of Pediatrics, Division of Pediatric Psychology, Oregon Health and Science University, Portland, OR, USA
| | - Trevor A Hall
- Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health and Science University, 707 SW Gaines St., CDRC-P, Portland, OR, 97239, USA
- Department of Pediatrics, Division of Pediatric Psychology, Oregon Health and Science University, Portland, OR, USA
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Rai S, Anthony L, Needham DM, Georgousopoulou EN, Sudheer B, Brown R, Mitchell I, van Haren F. Barriers to rehabilitation after critical illness: a survey of multidisciplinary healthcare professionals caring for ICU survivors in an acute care hospital. Aust Crit Care 2019; 33:264-271. [PMID: 31402265 DOI: 10.1016/j.aucc.2019.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/04/2019] [Accepted: 05/28/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND There is scant literature on the barriers to rehabilitation for patients discharged from the intensive care unit (ICU) to acute care wards. OBJECTIVES The objective of this study was to assess ward-based rehabilitation practices and barriers and assess knowledge and perceptions of ward clinicians regarding health concerns of ICU survivors. METHODS, DESIGN, SETTING, AND PARTICIPANTS This was a single-centre survey of multidisciplinary healthcare professionals caring for ICU survivors in an Australian tertiary teaching hospital. MAIN OUTCOME MEASURES The main outcome measures were knowledge of post-intensive care syndrome (PICS) amongst ward clinicians, perceptions of ongoing health concerns with current rehabilitation practices, and barriers to inpatient rehabilitation for ICU survivors. RESULTS The overall survey response rate was 35% (198/573 potential staff). Most respondents (66%, 126/190) were unfamiliar with the term PICS. A majority of the respondents perceived new-onset physical weakness, sleep disturbances, and delirium as common health concerns amongst ICU survivors on acute care wards. There were multifaceted barriers to patient mobilisation, with inadequate multidisciplinary staffing, lack of medical order for mobilisation, and inadequate physical space near the bed as common institutional barriers and patient frailty and cardiovascular instability as the commonly perceived patient-related barriers. A majority of the surveyed ward clinicians (66%, 115/173) would value education on health concerns of ICU survivors to provide better patient care. CONCLUSION There are multiple potentially modifiable barriers to the ongoing rehabilitation of ICU survivors in an acute care hospital. Addressing these barriers may have benefits for the ongoing care of ICU survivors.
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Affiliation(s)
- Sumeet Rai
- Canberra Hospital Intensive Care Unit, Garran, Canberra, Australia; Australian National University Medical School, Canberra, Australia.
| | - Lakmali Anthony
- Australian National University Medical School, Canberra, Australia
| | - Dale M Needham
- Critical Care Physical Medicine and Rehabilitation Program, John Hopkins Hospital, Baltimore, MD, USA; John Hopkins University School of Medicine and School of Nursing, Baltimore, MD, USA
| | | | - Bindu Sudheer
- Canberra Hospital Intensive Care Unit, Garran, Canberra, Australia; Australian Catholic University, Watson, Canberra, Australia
| | - Rhonda Brown
- Research School of Psychology, Australian National University, Canberra, Australia
| | - Imogen Mitchell
- Canberra Hospital Intensive Care Unit, Garran, Canberra, Australia; Australian National University Medical School, Canberra, Australia
| | - Frank van Haren
- Canberra Hospital Intensive Care Unit, Garran, Canberra, Australia; University of Canberra, Bruce, Canberra, Australia
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Geriatrische Rehabilitation herzchirurgischer Patienten. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00398-019-0308-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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23
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Ohtake PJ, Lee AC, Scott JC, Hinman RS, Ali NA, Hinkson CR, Needham DM, Shutter L, Smith-Gabai H, Spires MC, Thiele A, Wiencek C, Smith JM. Physical Impairments Associated With Post-Intensive Care Syndrome: Systematic Review Based on the World Health Organization's International Classification of Functioning, Disability and Health Framework. Phys Ther 2018; 98:631-645. [PMID: 29961847 DOI: 10.1093/ptj/pzy059] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 03/29/2018] [Indexed: 02/09/2023]
Abstract
BACKGROUND Post-intensive care syndrome (PICS) is a constellation of new or worsening impairments in physical, mental, or cognitive abilities or a combination of these in individuals who have survived critical illness requiring intensive care. PURPOSE The 2 purposes of this systematic review were to identify the scope and magnitude of physical problems associated with PICS during the first year after critical illness and to use the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework to elucidate impairments of body functions and structures, activity limitations, and participation restrictions associated with PICS. DATA SOURCES Ovid MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, CINAHL Plus with Full Text (EBSCO), Web of Science, and Embase were searched from inception until March 7, 2017. STUDY SELECTION Two reviewers screened titles, abstracts, and full text to independently determine study eligibility based on inclusion and exclusion criteria. DATA EXTRACTION Study methodological quality was assessed using the Newcastle-Ottawa Scale. Data describing study methods, design, and participant outcomes were extracted. DATA SYNTHESIS Fifteen studies were eligible for review. Within the first year following critical illness, people who had received intensive care experienced impairments in all 3 domains of the ICF (body functions and structures, activity limitations, and participation restrictions). These impairments included decreased pulmonary function, reduced strength of respiratory and limb muscles, reduced 6-minute walk test distance, reduced ability to perform activities of daily living and instrumental activities of daily living, and reduced ability to return to driving and paid employment. LIMITATIONS The inclusion of only 15 observational studies in this review may limit the generalizability of the findings. CONCLUSIONS During the first year following critical illness, individuals with PICS experienced physical impairments in all 3 domains of the ICF.
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Affiliation(s)
- Patricia J Ohtake
- Department of Rehabilitation Science, University at Buffalo, 515 Kimball Tower, Buffalo, NY 14214 (USA)
| | - Alan C Lee
- Department of Physical Therapy, Mount St Mary's University, Los Angeles, California
| | | | - Rana S Hinman
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Naeem A Ali
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Carl R Hinkson
- Respiratory Care, Providence Regional Medical Center Everett, Everett, Washington
| | - Dale M Needham
- Pulmonary & Critical Care Medicine and Physical Medicine & Rehabilitation, Johns Hopkins University, Baltimore, Maryland
| | - Lori Shutter
- Critical Care Medicine, UPMC/University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Helene Smith-Gabai
- Program in Occupational Therapy, Brenau University, Gainesville, Georgia
| | - Mary C Spires
- Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan
| | | | - Clareen Wiencek
- School of Nursing, University of Virginia, Charlottesville, Virginia
| | - James M Smith
- Physical Therapy Department, Utica College, Utica, New York
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Taito S, Taito M, Banno M, Tsujimoto H, Kataoka Y, Tsujimoto Y. Rehabilitation for patients with sepsis: A systematic review and meta-analysis. PLoS One 2018; 13:e0201292. [PMID: 30048540 PMCID: PMC6062068 DOI: 10.1371/journal.pone.0201292] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 07/12/2018] [Indexed: 12/29/2022] Open
Abstract
The objective of this systematic review was to determine whether rehabilitation impacts clinically relevant outcomes among adult patients with sepsis. Randomized controlled trials from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PEDro, and the World Health Organization International Clinical Trials Platform Search Portal, as well as conference proceedings and reference lists of relevant articles were collected. Two reviewers independently identified randomized controlled trials on the rehabilitation of patients with sepsis, and the two reviewers independently abstracted trial level data including population characteristics, interventions, comparisons, and clinical outcomes. Our primary outcomes were quality of life (QOL), activity of daily living (ADL), and mortality. Our secondary outcomes were length of stay, return to work, muscle strength, delirium, and all adverse events. The quality of evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. We included two trials enrolling 75 patients. The mean difference (95% confidence interval [CI]) of physical function and physical role in QOL measured by SF-36 were 21.10 (95% CI: 6.57–35.63) and 44.40 (95% CI: 22.55–66.05), respectively. Rehabilitation did not significantly decrease intensive care unit (ICU) mortality (risk ratio, 2.02 [95% CI: 0.46–8.91], I2 = 0%; n = 75). ICU length of stay and hospital length of stay and muscle strength were not statistically significantly different and no adverse events were reported in both studies. The certainty of the evidence for these outcomes was “very low.” Data on ADL, return to work, and delirium were not available in any of the trials. Rehabilitation of patients with sepsis might not decrease ICU mortality, but might improve QOL. Further, well-designed trials measuring important outcomes will be needed to determine the benefit and harm of rehabilitation among patients with sepsis.
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Affiliation(s)
- Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
- * E-mail:
| | - Mahoko Taito
- Department of Nursing, Hiroshima University Hospital, Hiroshima, Japan
| | - Masahiro Banno
- Department of Psychiatry, Seichiryo Hospital, Nagoya, Aichi, Japan
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Hiraku Tsujimoto
- Hospital Care Research Unit, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Yuki Kataoka
- Hospital Care Research Unit, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
- Department of Respiratory Medicine, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - Yasushi Tsujimoto
- Department of Healthcare Epidemiology, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Nephrology and Dialysis, Kyoritsu Hospital, Hyogo, Japan
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A Systematic Review of Risk Factors Associated With Cognitive Impairment After Pediatric Critical Illness. Pediatr Crit Care Med 2018; 19:e164-e171. [PMID: 29329164 DOI: 10.1097/pcc.0000000000001430] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To identify risk factors associated with cognitive impairment as assessed by neuropsychologic tests in neurotypical children after critical illness. DATA SOURCES For this systematic review, we searched the Cochrane Library, Scopus, PubMed, Ovid, Embase, and CINAHL databases from January 1960 to March 2017. STUDY SELECTION Included were studies with subjects 3-18 years old at the time of post PICU follow-up evaluation and use of an objective standardized neuropsychologic test with at least one cognitive functioning dimension. Excluded were studies featuring patients with a history of cardiac arrest, traumatic brain injury, or genetic anomalies associated with neurocognitive impairment. DATA EXTRACTION Twelve studies met the sampling criteria and were rated using the Newcastle-Ottawa Quality Assessment Scale. DATA SYNTHESIS Ten studies reported significantly lower scores in at least one cognitive domain as compared to healthy controls or normed population data; seven of these-four case-control and three prospective cohort studies-reported significant lower scores in more than one cognitive domain. Risk factors associated with post critical illness cognitive impairment included younger age at critical illness and/or older age at follow-up, low socioeconomic status, high oxygen requirements, and use of mechanical ventilation, sedation, and pain medications. CONCLUSIONS Identifying risk factors for poor cognitive outcomes post critical illness may help healthcare teams modify patient risk and/or provide follow-up services to improve long-term cognitive outcomes in high-risk children.
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Resilience in Survivors of Critical Illness in the Context of the Survivors' Experience and Recovery. Ann Am Thorac Soc 2018; 13:1351-60. [PMID: 27159794 DOI: 10.1513/annalsats.201511-782oc] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
RATIONALE Post-intensive care syndrome (PICS), defined as new or worsening impairment in cognition, mental health, or physical function after critical illness, is an important development in survivors. Although studies to date have focused on the frequency of these impairments, fundamental questions remain unanswered regarding the survivor experience and the impact of the critical illness event on survivor resilience and recovery. OBJECTIVES To examine the association between resilience and neuropsychological and physical function and to contextualize these findings within the survivors' recovery experience. METHODS We conducted a mixed-methods pilot investigation of resilience among 43 survivors from two medical intensive care units (ICUs) within an academic health-care system. We interviewed survivors to identify barriers to and facilitators of recovery in the ICU, on the medical ward, and at home, using qualitative methods. We used a telephone battery of standardized tests to examine resilience, neuropsychological and physical function, and quality of life. We examined PICS in two ways. First, we identified how frequently survivors were impaired in one or more domains 6-12 months postdischarge. Second, we identified how frequently survivors reported that neuropsychological or physical function was worse. MEASUREMENTS AND MAIN RESULTS Resilience was low in 28% of survivors, normal in 63% of survivors, and high in 9% of survivors. Resilience was inversely correlated with self-reported executive dysfunction, symptoms of anxiety, depression, and post-traumatic stress disorder, difficulty with self-care, and pain (P < 0.05). PICS was present in 36 survivors (83.7%; 95% confidence interval, 69.3-93.2%), whereas 23 survivors (53.5%; 95% confidence interval, 37.6-68.8%) reported worsening of neuropsychological or physical function after critical illness. We identified challenges along the recovery path of ICU survivors, finding that physical limitations and functional dependence were the most frequent challenges experienced in the ICU, medical ward, and on return to home. Spiritual and family support facilitated recovery. CONCLUSIONS Resilience was inversely correlated with neuropsychological impairment, pain, and difficulty with self-care. PICS was present in most survivors of critical illness, and 54% reported neuropsychological or physical function to be worse, yet resilience was normal or high in most survivors. Survivors experienced many challenges during recovery, while spiritual and family support facilitated recovery.
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Therapeutic Advances in the Management of Older Adults in the Intensive Care Unit: A Focus on Pain, Sedation, and Delirium. Am J Ther 2018. [DOI: 10.1097/mjt.0000000000000685] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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O'Gara G, Tuddenham S, Pattison N. Haemato-oncology patients' perceptions of health-related quality of life after critical illness: A qualitative phenomenological study. Intensive Crit Care Nurs 2017; 44:76-84. [PMID: 29056247 DOI: 10.1016/j.iccn.2017.09.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/19/2017] [Accepted: 09/26/2017] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Haemato-oncology patients often require critical care support due to side-effects of treatment. Discharge can mark the start of an uncertain journey due to the impact of critical illness on health-related quality of life. Qualitatively establishing needs is a priority as current evidence is limited. AIMS To qualitatively explore perceptions of haemato-oncology patients' health-related quality of life after critical illness and explore how healthcare professionals can provide long-term support. METHODS Nine in-depth interviews were conducted three to eighteen months post-discharge from critical care. Phenomenology was used to gain deeper understanding of the patients' lived experience. SETTING A 19-bedded Intensive Care Unit in a specialist cancer centre. FINDINGS Five major themes emerged: Intensive care as a means to an end; Rollercoaster of illness; Reliance on hospital; Having a realistic/sanguine approach; Living in the moment. Haemato-oncology patients who experience critical illness may view it as a small part of a larger treatment pathway, thus health-related quality of life is impacted by this rather than the acute episode. CONCLUSIONS Discharge from the intensive care unit can be seen as a positive end-point, allowing personal growth in areas such as relationships and living life to the full. The contribution of health-care professionals and support of significant others is regarded as critical to the recovery experience.
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Affiliation(s)
- Geraldine O'Gara
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, United Kingdom. Geraldine.O'
| | | | - Natalie Pattison
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, United Kingdom.
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Hashmi AM, Han JY, Demla V. Intensive Care and its Discontents: Psychiatric Illness in the Critically Ill. Psychiatr Clin North Am 2017; 40:487-500. [PMID: 28800804 DOI: 10.1016/j.psc.2017.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Critically ill patients can develop a host of cognitive and psychiatric complaints during their intensive care unit (ICU) stay, many of which persist for weeks or months following discharge from the ICU and can seriously affect their quality of life, including their ability to return to work. This article describes some common psychiatric problems encountered by clinicians in the ICU, including their assessment and management. A comprehensive approach is needed to decrease patient suffering, improve morbidity and mortality, and ensure that critically ill patients can return to the highest quality of life after an ICU stay.
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Affiliation(s)
- Ali M Hashmi
- Department of Psychiatry and Behavioral Sciences, King Edward Medical University/Mayo Hospital, Neela Gumbad, Lahore-54700, Pakistan.
| | - Jin Y Han
- Menninger Department of Psychiatry and Behavioral Sciences, Department of Family and Community Medicine, Baylor College of Medicine, 1502 Taub Loop NPC 2nd Floor, Houston, TX 77030, USA
| | - Vishal Demla
- Division of Critical Care Medicine, Department of Internal Medicine, University of Texas Health Science Center, 6431 Fannin, MSB 1.150, Houston, TX 77030, USA
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Hopkins RO, Mitchell L, Thomsen GE, Schafer M, Link M, Brown SM. Implementing a Mobility Program to Minimize Post-Intensive Care Syndrome. AACN Adv Crit Care 2017; 27:187-203. [PMID: 27153308 DOI: 10.4037/aacnacc2016244] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Immobility in the intensive care unit (ICU) is associated with neuromuscular weakness, post-intensive care syndrome, functional limitations, and high costs. Early mobility-based rehabilitation in the ICU is feasible and safe. Mobility-based rehabilitation varied widely across 5 ICUs in 1 health care system, suggesting a need for continuous training and evaluation to maintain a strong mobility-based rehabilitation program. Early mobility-based rehabilitation shortens ICU and hospital stays, reduces delirium, and increases muscle strength and the ability to ambulate. Long-term effects include increased ability for self-care, faster return to independent functioning, improved physical function, and reduced hospital readmission and death. Factors that influence early mobility-based rehabilitation include having an interdisciplinary team; strong unit leadership; access to physical, occupational, and respiratory therapists; a culture focused on patient safety and quality improvement; a champion of early mobility; and a focus on measuring performance and outcomes.
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Affiliation(s)
- Ramona O Hopkins
- Ramona O. Hopkins is Professor, Department of Psychology and Neuroscience Center, Brigham Young University, Provo, Utah, and Clinical Research Investigator, Center for Humanizing Critical Care, and Department of Medicine, Pulmonary and Critical Care Division, Intermountain Healthcare, 5121 South Cottonwood St, Murray, UT 84107 . Lorie Mitchell is Nurse Manager, Shock Trauma Intensive Care Unit, Department of Medicine, Intermountain Medical Center. George E. Thomsen is Medical Director, Coronary Intensive Care Unit, Department of Medicine, Intermountain Medical Center. Michele Schafer is Member, Intensive Care Unit Patient-Family Advisory Council, Intermountain Medical Center. Maggie Link is Physical Therapist, Shock Trauma Intensive Care Unit, Intermountain Medical Center. Samuel M. Brown is Director, Center for Humanizing Critical Care, Assistant Professor of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Healthcare, and University of Utah School of Medicine, Salt Lake City, Utah
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Sharma NS, Hartwig MG, Hayes D. Extracorporeal membrane oxygenation in the pre and post lung transplant period. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:74. [PMID: 28275619 DOI: 10.21037/atm.2017.02.09] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Evolution in technology has resulted in rapid increase in utilization of extracorporeal membrane oxygenation (ECMO) as a bridge to recovery and/or transplantation. Although there is limited evidence for the use of ECMO, recent improvements in ECMO technology, personnel training, ambulatory practices on ECMO and lung protective strategies have resulted in improved outcomes in patients bridged to lung transplantation. This review provides an insight into the current outcomes and best practices for utilization of ECMO in the pre- and post-lung transplantation period.
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Affiliation(s)
- Nirmal S Sharma
- Division of Pulmonary, Allergy & Critical Care Medicine, University of Alabama at Birmingham, Birmingham AL, USA
| | - Mathew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University, Durham, NC, USA
| | - Don Hayes
- Departments of Pediatrics, Internal Medicine, and Surgery, The Ohio State University, OH, USA
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Álvarez EA, Garrido MA, Tobar EA, Prieto SA, Vergara SO, Briceño CD, González FJ. Occupational therapy for delirium management in elderly patients without mechanical ventilation in an intensive care unit: A pilot randomized clinical trial. J Crit Care 2017; 37:85-90. [DOI: 10.1016/j.jcrc.2016.09.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 07/29/2016] [Accepted: 09/03/2016] [Indexed: 10/21/2022]
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Ohtake PJ, Coffey Scott J, Hinman RS, Lee AC, Smith JM. Impairments, activity limitations and participation restrictions experienced in the first year following a critical illness: protocol for a systematic review. BMJ Open 2017; 7:e013847. [PMID: 28119388 PMCID: PMC5278234 DOI: 10.1136/bmjopen-2016-013847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Critical illness requiring intensive care unit (ICU) management is a life-altering event with ∼25% of ICU survivors experiencing persistent reductions in physical functioning, impairments in mental health, cognitive dysfunction and decreased quality of life. This constellation of problems is known as 'postintensive care syndrome' (PICS) and may persist for months and/or years. The purpose of this systematic review is to identify the scope and magnitude of physical problems associated with PICS during the first year after discharge from ICU, using the International Classification of Functioning, Disability and Health framework to elucidate the impairments of body functions and structures, activity limitations and participation restrictions. METHODS AND ANALYSIS Medline (Ovid), Cochrane Database of Systematic Reviews (Ovid), Cochrane Central Register of Controlled Trials (Ovid), PubMed, CINAHL (EBSCO), Web of Science and EMBASE will be systematically searched for observational studies reporting the physical impairments of body functions and structures, activity limitations and participation restrictions associated with PICS. Two reviewers will assess the articles for eligibility according to prespecified selection criteria, after which an independent reviewer will perform data extraction which will be validated by a second independent reviewer. Quality appraisal will be performed by two independent reviewers. Outcomes of the included studies will be summarised in tables and in narrative format and meta-analyses will be conducted where appropriate. ETHICS AND DISSEMINATION Formal ethical approval is not required as no primary data is collected. This systematic review will identify the scope and magnitude of physical problems associated with PICS during the first year after discharge from ICU and will be disseminated through a peer-reviewed publication and at conference meetings, to inform practice and future research on the physical problems associated with PICS. TRIAL REGISTRATION NUMBER CRD42015023520.
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Affiliation(s)
- Patricia J Ohtake
- Department of Rehabilitation Science, University at Buffalo, Buffalo, New York, USA
| | | | - Rana S Hinman
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Alan Chong Lee
- Department of Physical Therapy, Mount Saint Mary's University, Los Angeles, California, USA
| | - James M Smith
- Physical Therapy Department, Utica College, Utica, New York, USA
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Sepulveda-Pacsi AL, Soderman M, Kertesz L. Nurses' perceptions of their knowledge and barriers to ambulating hospitalized patients in acute settings. Appl Nurs Res 2016; 32:117-121. [PMID: 27969013 DOI: 10.1016/j.apnr.2016.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 05/19/2016] [Accepted: 06/06/2016] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this study was to understand nurses' knowledge and perceptions of the importance of patient ambulation in acute care hospital settings. The data obtained from this survey will be used to create improvement initiatives that address patient ambulation. METHOD An exploratory, cross-sectional study using a self-administered survey was conducted in two different hospital sites, and was completed by 192 nurses. A modified version of the validated and reliable tool entitled "Missed Nursing Care Survey" was used. Multivariate regressions were used to determine the relationship of demographic and workplace variables to nurses' knowledge and perceptions regarding acute adult-inpatient ambulation. RESULTS The primary factors interfering with ambulating patients were inadequate number of staff (both clerical and nursing), urgent patient situations, and unexpected rises in patient volume and/or acuity on the unit. Small associations were found between knowledge of ambulation and years of experience, and shift worked. CONCLUSION Study findings add to the body of knowledge by providing insight into what variables influence urban nurses' knowledge and perceptions of barriers faced when ambulating acute adult-inpatients in acute hospitalized settings. The study results can be used to develop strategies and improvement initiatives that address acute adult-inpatient ambulation in acute settings and address the perceived barriers to this process. The ultimate goal is to improve the quality of care delivered, improve patient outcomes, and promote patient well-being. Implication for nursing practice, research and education will be discussed.
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Affiliation(s)
- Alsacia L Sepulveda-Pacsi
- School of Nursing Columbia University, New York; New York Presbyterian Departments of Nursing: Adult Emergency Room and Operating Room.
| | - Mary Soderman
- New York Presbyterian Departments of Nursing: Adult Emergency Room and Operating Room
| | - Louise Kertesz
- New York Presbyterian Departments of Nursing: Adult Emergency Room and Operating Room
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Hickmann CE, Castanares-Zapatero D, Bialais E, Dugernier J, Tordeur A, Colmant L, Wittebole X, Tirone G, Roeseler J, Laterre PF. Teamwork enables high level of early mobilization in critically ill patients. Ann Intensive Care 2016; 6:80. [PMID: 27553652 PMCID: PMC4995191 DOI: 10.1186/s13613-016-0184-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 08/15/2016] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Early mobilization in critically ill patients has been shown to prevent bed-rest-associated morbidity. Reported reasons for not mobilizing patients, thereby excluding or delaying such intervention, are diverse and comprise safety considerations for high-risk critically ill patients with multiple organ support systems. This study sought to demonstrate that early mobilization performed within the first 24 h of ICU admission proves to be feasible and well tolerated in the vast majority of critically ill patients. RESULTS General practice data were collected for 171 consecutive admissions to our ICU over a 2-month period according to a local, standardized, early mobilization protocol. The total period covered 731 patient-days, 22 (3 %) of which met our local exclusion criteria for mobilization. Of the remaining 709 patient-days, early mobilization was achieved on 86 % of them, bed-to-chair transfer on 74 %, and at least one physical therapy session on 59 %. Median time interval from ICU admission to the first early mobilization activity was 19 h (IQR = 15-23). In patients on mechanical ventilation (51 %), accounting for 46 % of patient-days, 35 % were administered vasopressors and 11 % continuous renal replacement therapy. Within this group, bed-to-chair transfer was achieved on 68 % of patient-days and at least one early mobilization activity on 80 %. Limiting factors to start early mobilization included restricted staffing capacities, diagnostic or surgical procedures, patients' refusal, as well as severe hemodynamic instability. Hemodynamic parameters were rarely affected during mobilization, causing interruption in only 0.8 % of all activities, primarily due to reversible hypotension or arrhythmia. In general, all activities were well tolerated, while patients were able to self-regulate their active early mobilization. Patients' subjective perception of physical therapy was reported to be enjoyable. CONCLUSIONS Mobilization within the first 24 h of ICU admission is achievable in the majority of critical ill patients, in spite of mechanical ventilation, vasopressor administration, or renal replacement therapy.
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Affiliation(s)
- Cheryl Elizabeth Hickmann
- Intensive Care Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Diego Castanares-Zapatero
- Intensive Care Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Emilie Bialais
- Intensive Care Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Jonathan Dugernier
- Intensive Care Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Antoine Tordeur
- Intensive Care Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Lise Colmant
- Intensive Care Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Xavier Wittebole
- Intensive Care Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Giuseppe Tirone
- Intensive Care Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Jean Roeseler
- Intensive Care Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Pierre-François Laterre
- Intensive Care Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCL), Avenue Hippocrate 10, 1200 Brussels, Belgium
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Connolly B, Salisbury L, O'Neill B, Geneen L, Douiri A, Grocott MPW, Hart N, Walsh TS, Blackwood B. Exercise rehabilitation following intensive care unit discharge for recovery from critical illness: executive summary of a Cochrane Collaboration systematic review. J Cachexia Sarcopenia Muscle 2016; 7:520-526. [PMID: 27891297 PMCID: PMC5114628 DOI: 10.1002/jcsm.12146] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/02/2016] [Indexed: 01/26/2023] Open
Abstract
Skeletal muscle wasting and weakness are major complications of critical illness and underlie the profound physical and functional impairments experienced by survivors after discharge from the intensive care unit (ICU). Exercise-based rehabilitation has been shown to be beneficial when delivered during ICU admission. This review aimed to determine the effectiveness of exercise rehabilitation initiated after ICU discharge on primary outcomes of functional exercise capacity and health-related quality of life. We sought randomized controlled trials, quasi-randomized controlled trials, and controlled clinical trials comparing an exercise intervention commenced after ICU discharge vs. any other intervention or a control or 'usual care' programme in adult survivors of critical illness. Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database, and Cumulative Index to Nursing and Allied Health Literature databases were searched up to February 2015. Dual, independent screening of results, data extraction, and quality appraisal were performed. We included six trials involving 483 patients. Overall quality of evidence for both outcomes was very low. All studies evaluated functional exercise capacity, with three reporting positive effects in favour of the intervention. Only two studies evaluated health-related quality of life and neither reported differences between intervention and control groups. Meta-analyses of data were precluded due to variation in study design, types of interventions, and selection and reporting of outcome measurements. We were unable to determine an overall effect on functional exercise capacity or health-related quality of life of interventions initiated after ICU discharge for survivors of critical illness. Findings from ongoing studies are awaited. Future studies need to address methodological aspects of study design and conduct to enhance rigour, quality, and synthesis.
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Affiliation(s)
- Bronwen Connolly
- Lane Fox Clinical Respiratory Physiology Research UnitGuy's and St Thomas' NHS Foundation TrustLondonUK
- Division of Asthma, Allergy, and Lung BiologyKing's College LondonLondonUK
- National Institute of Health Research Biomedical Research CentreGuy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
| | - Lisa Salisbury
- Edinburgh Critical Care Research Group MRC Centre for Inflammation ResearchUniversity of EdinburghEdinburghUK
| | - Brenda O'Neill
- Institute of Nursing and Health Research, School of Health SciencesUlster UniversityNewtownabbeyUK
| | - Louise Geneen
- School of Medicine, College of Medicine, Dentistry, and NursingUniversity of DundeeDundeeUK
| | - Abdel Douiri
- National Institute of Health Research Biomedical Research CentreGuy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
- Department of Public Health Sciences, Division of Health and Social Care ResearchKing's College LondonLondonUK
| | - Michael P. W. Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental SciencesUniversity of SouthamptonSouthamptonUK
- Critical Care Research AreaSouthampton NIHR Respiratory Biomedical Research UnitSouthamptonUK
- Anaesthesia and Critical Care Research UnitUniversity Hospital Southampton NHS Foundation TrustSouthamptonUK
| | - Nicholas Hart
- Lane Fox Clinical Respiratory Physiology Research UnitGuy's and St Thomas' NHS Foundation TrustLondonUK
- Division of Asthma, Allergy, and Lung BiologyKing's College LondonLondonUK
- National Institute of Health Research Biomedical Research CentreGuy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
| | | | - Bronagh Blackwood
- Health Sciences, School of Medicine, Dentistry, and Biomedical Sciences, Centre for Infection and ImmunityQueen's University BelfastBelfastUK
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Ward D, Fulbrook P. Nursing Strategies for Effective Weaning of the Critically Ill Mechanically Ventilated Patient. Crit Care Nurs Clin North Am 2016; 28:499-512. [PMID: 28236395 DOI: 10.1016/j.cnc.2016.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The risks imposed by mechanical ventilation can be mitigated by nurses' use of strategies that promote early but appropriate reduction of ventilatory support and timely extubation. Weaning from mechanical ventilation is confounded by the multiple impacts of critical illness on the body's systems. Effective weaning strategies that combine several interventions that optimize weaning readiness and assess readiness to wean, and use a weaning protocol in association with spontaneous breathing trials, are likely to reduce the requirement for mechanical ventilatory support in a timely manner. Weaning strategies should be reviewed and updated regularly to ensure congruence with the best available evidence.
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Affiliation(s)
- Darian Ward
- Education, Training and Research, Wide Bay Hospital and Health Service, 65 Main Street, Hervey Bay, Queensland 4655, Australia.
| | - Paul Fulbrook
- Nursing Research and Practice Development Centre, The Prince Charles Hospital, Brisbane 4032, Australia; School of Nursing, Midwifery and Paramedicine, Australian Catholic University, 1100 Nudgee Road, Brisbane 4014, Australia
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Ten reasons why ICU patients should be mobilized early. Intensive Care Med 2016; 43:86-90. [PMID: 27562244 DOI: 10.1007/s00134-016-4513-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 08/16/2016] [Indexed: 10/21/2022]
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Palanisamy A, Friese MB, Cotran E, Moller L, Boyd JD, Crosby G, Culley DJ. Prolonged Treatment with Propofol Transiently Impairs Proliferation but Not Survival of Rat Neural Progenitor Cells In Vitro. PLoS One 2016; 11:e0158058. [PMID: 27379684 PMCID: PMC4933334 DOI: 10.1371/journal.pone.0158058] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 06/09/2016] [Indexed: 12/12/2022] Open
Abstract
Neurocognitive dysfunction is common in survivors of intensive care. Prolonged sedation has been implicated but the mechanisms are unclear. Neurogenesis continues into adulthood and is implicated in learning. The neural progenitor cells (NPC) that drive neurogenesis have receptors for the major classes of sedatives used clinically, suggesting that interruption of neurogenesis may partly contribute to cognitive decline in ICU survivors. Using an in vitro system, we tested the hypothesis that prolonged exposure to propofol concentration- and duration-dependently kills or markedly decreases the proliferation of NPCs. NPCs isolated from embryonic day 14 Sprague-Dawley rat pups were exposed to 0, 2.5, or 5.0 μg/mL of propofol, concentrations consistent with deep clinical anesthesia, for either 4 or 24 hours. Cells were assayed for cell death and proliferation either immediately following propofol exposure or 24 hours later. NPC death and apoptosis were measured by propidium iodine staining and cleaved caspase-3 immunocytochemistry, respectively, while proliferation was measured by EdU incorporation. Staurosporine (1μM for 6h) was used as a positive control for cell death. Cells were analyzed with unbiased high-throughput immunocytochemistry. There was no cell death at either concentration of propofol or duration of exposure. Neither concentration of propofol impaired NPC proliferation when exposure lasted 4 h, but when exposure lasted 24 h, propofol had an anti-proliferative effect at both concentrations (P < 0.0001, propofol vs. control). However, this effect was transient; proliferation returned to baseline 24 h after discontinuation of propofol (P = 0.37, propofol vs. control). The transient but reversible suppression of NPC proliferation, absence of cytotoxicity, and negligible effect on the neural stem cell pool pool suggest that propofol, even in concentrations used for clinical anesthesia, has limited impact on neural progenitor cell biology.
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Affiliation(s)
- Arvind Palanisamy
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Matthew B. Friese
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Emily Cotran
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ludde Moller
- Faculty of Pharmacy, Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Justin D. Boyd
- Laboratory for Drug Discovery in Neurodegeneration (LDDN), Harvard NeuroDiscovery Center, Harvard Medical School, Cambridge, Massachusetts, United States of America
| | - Gregory Crosby
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Deborah J. Culley
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
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Maley JH, Mikkelsen ME. Short-term Gains with Long-term Consequences: The Evolving Story of Sepsis Survivorship. Clin Chest Med 2016; 37:367-80. [PMID: 27229651 DOI: 10.1016/j.ccm.2016.01.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Sepsis is an acute, life-threatening condition that afflicts millions of patients annually. Advances in care and heightened awareness have led to substantial declines in short-term mortality. An expanding body of literature describes the long-term impact of sepsis, revealing long-term cognitive and functional impairments, sustained inflammation and immune dysfunction, increased healthcare resource use, reduced health-related quality of life, and increased mortality. The evidence challenges the notion that sepsis is an acute, transient illness, revealing rather that sepsis is an acute illness with lingering consequences. This article provides a state-of-the-art review of the emerging literature of the long-term consequences of sepsis.
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Affiliation(s)
- Jason H Maley
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Mark E Mikkelsen
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Dafoe S, Chapman MJ, Edwards S, Stiller K. Overcoming barriers to the mobilisation of patients in an intensive care unit. Anaesth Intensive Care 2016; 43:719-27. [PMID: 26603796 DOI: 10.1177/0310057x1504300609] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
We conducted a quality improvement project aimed at increasing the frequency of mobilisation in our ICU. We designed a four-part quality improvement project comprising: an audit documenting the baseline frequency of mobilisation; a staff survey evaluating perceptions of the barriers to mobilisation; identification of barriers that were amenable to change and implementation of strategies to address these; and a follow-up audit to determine their effectiveness. The setting was a tertiary care, urban, public hospital ICU in South Australia. All patients admitted to the ICU during the two audit periods were included in the audits, while all permanent/semi-permanent ICU staff were eligible for inclusion in the staff survey. We found that patient- and institution-related factors had the greatest impact on the mobilisation of patients in our ICU. Barriers identified as being amenable to change included insufficient staff education about the benefits of mobilisation, poor interdisciplinary communication and lack of leadership regarding mobilisation. Various strategies were implemented to address these barriers over a three-month period. Multivariable analyses showed that three out of four mobility outcomes did not significantly change between the baseline and follow-up audits, with a significant difference in favour of the baseline audit found for the fourth mobility outcome (maximum level of mobility). We concluded that implementing relatively simple measures to improve staff education, interdisciplinary communication and leadership regarding early progressive mobilisation was ineffective at improving mobility outcomes for patients in a large tertiary-level Australian ICU. Other strategies, such as changing sedation practices and/or increasing staffing, may be required to improve mobility outcomes of these patients.
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Affiliation(s)
- S Dafoe
- Acute Care and surgery, Physiotherapy Department, Royal Adelaide Hospital, Adelaide, South Australia
| | - M J Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia
| | - S Edwards
- Data Management and Analysis Centre, University of Adelaide, Adelaide, South Australia
| | - K Stiller
- Physiotherapy Department, Royal Adelaide Hospital, Adelaide, South Australia
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Heeder C, Azocar RJ, Tsai A. ICU Delirium: Diagnosis, Risk Factors, and Management. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-015-0125-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
Identification and adoption of strategies to promote timely and successful weaning from mechanical ventilation remain a research and quality improvement priority. The most important steps in the weaning process to prevent unnecessary prolongation of mechanical ventilation are timely recognition of both readiness to wean and readiness to extubate. Strategies shown to be effective in promoting timely weaning include weaning protocols and use of spontaneous breathing trials. This review explores various other strategies that also may promote timely and successful weaning including bundling of spontaneous breathing trials with sedation and delirium monitoring/management as well as early mobility, the use of automated weaning systems and modes that improve patient-ventilator interaction, mechanical insufflation-exsufflation as a weaning adjunct, early extubation to non-invasive ventilation and high flow humidified oxygen. As most critically ill patients requiring mechanical ventilation will tolerate extubation with minimal weaning, identification of strategies to improve management of those patients experiencing difficult and prolonged weaning should be a priority for clinical practice, quality improvement initiatives and weaning research.
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Affiliation(s)
- Louise Rose
- Critical Care Research, Sunnybrook Health Sciences Centre, Canada; Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada; Provincial Centre of Weaning Excellence, Toronto East General Hospital, Canada; Institute for Clinical Evaluative Sciences, Canada; Li Ka Shing Institute, St Michael's Hospital, Canada; West Park Healthcare Centre, Canada; Canadian Institutes of Health Research (CIHR) New Investigator, Canada.
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Abstract
In this monograph, the message is that early inactivity and obesity lead to later chronic disease, and, as such, physical inactivity should be recognized as a public health crisis. Sedentary behavior, to some extent, serves a purpose in our current culture (e.g., keeping children indoors keeps them safe), and, as such, may not be amenable to change. Thus, it is important that we understand the underpinnings of later-developing chronic disease as this complex public health issue may have roots that go deeper than sedentary behavior. In this commentary, I speculate on the mechanisms for physical activity exacting positive changes on cognitive abilities. Three potential mechanisms are discussed: glucose transport, postnatal neurogenesis, and vitamin synthesis, all of which are inextricably linked to nutrition. This discussion of mechanisms is followed by a discussion of tractable correlates of the progression to non-communicable disease in the adult.
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Connolly B, Salisbury L, O'Neill B, Geneen LJ, Douiri A, Grocott MPW, Hart N, Walsh TS, Blackwood B. Exercise rehabilitation following intensive care unit discharge for recovery from critical illness. Cochrane Database Syst Rev 2015; 2015:CD008632. [PMID: 26098746 PMCID: PMC6517154 DOI: 10.1002/14651858.cd008632.pub2] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Skeletal muscle wasting and weakness are significant complications of critical illness, associated with degree of illness severity and periods of reduced mobility during mechanical ventilation. They contribute to the profound physical and functional deficits observed in survivors. These impairments may persist for many years following discharge from the intensive care unit (ICU) and can markedly influence health-related quality of life. Rehabilitation is a key strategy in the recovery of patients after critical illness. Exercise-based interventions are aimed at targeting this muscle wasting and weakness. Physical rehabilitation delivered during ICU admission has been systematically evaluated and shown to be beneficial. However, its effectiveness when initiated after ICU discharge has yet to be established. OBJECTIVES To assess the effectiveness of exercise rehabilitation programmes, initiated after ICU discharge, for functional exercise capacity and health-related quality of life in adult ICU survivors who have been mechanically ventilated longer than 24 hours. SEARCH METHODS We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid SP MEDLINE, Ovid SP EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host to 15 May 2014. We used a specific search strategy for each database. This included synonyms for ICU and critical illness, exercise training and rehabilitation. We searched the reference lists of included studies and contacted primary authors to obtain further information regarding potentially eligible studies. We also searched major clinical trials registries (Clinical Trials and Current Controlled Trials) and the personal libraries of the review authors. We applied no language or publication restriction. We reran the search in February 2015 and will deal with the three studies of interest when we update the review. SELECTION CRITERIA We included randomized controlled trials (RCTs), quasi-RCTs and controlled clinical trials (CCTs) that compared an exercise intervention initiated after ICU discharge versus any other intervention or a control or 'usual care' programme in adult (≥ 18 years) survivors of critical illness. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by the Cochrane Collaboration. MAIN RESULTS We included six trials (483 adult ICU participants). Exercise-based interventions were delivered on the ward in two studies; both on the ward and in the community in one study; and in the community in three studies. The duration of the intervention varied according to length of hospital stay following ICU discharge (up to a fixed duration of 12 weeks).Risk of bias was variable for all domains across all trials. High risk of bias was evident in all studies for performance bias, although blinding of participants and personnel in therapeutic rehabilitation trials can be pragmatically challenging. For other domains, at least half of the studies were at low risk of bias. One study was at high risk of selection bias, attrition bias and other sources of bias. Risk of bias was unclear for the remaining studies across domains. We decided not to undertake a meta-analysis because of variation in study design, types of interventions and outcome measurements. We present a narrative description of individual studies for each outcome.All six studies assessed functional exercise capacity, although we noted wide variability in the nature of interventions, outcome measures and associated metrics and data reporting. Overall quality of the evidence was very low. Individually, three studies reported positive results in favour of the intervention. One study found a small short-term benefit in anaerobic threshold (mean difference (MD) 1.8 mL O2/kg/min, 95% confidence interval (CI) 0.4 to 3.2; P value = 0.02). In a second study, both incremental (MD 4.7, 95% CI 1.69 to 7.75 watts; P value = 0.003) and endurance (MD 4.12, 95% CI 0.68 to 7.56 minutes; P value = 0.021) exercise testing results were improved with intervention. Finally self reported physical function increased significantly following use of a rehabilitation manual (P value = 0.006). Remaining studies found no effect of the intervention.Similar variability was evident with regard to findings for the primary outcome of health-related quality of life. Only two studies evaluated this outcome. Individually, neither study reported differences between intervention and control groups for health-related quality of life due to the intervention. Overall quality of the evidence was very low.Four studies reported rates of withdrawal, which ranged from 0% to 26.5% in control groups, and from 8.2% to 27.6% in intervention groups. The quality of evidence for the effect of the intervention on withdrawal was low. Very low-quality evidence showed rates of adherence with the intervention. Mortality ranging from 0% to 18.8% was reported by all studies. The quality of evidence for the effect of the intervention on mortality was low. Loss to follow-up, as reported in all studies, ranged from 0% to 14% in control groups, and from 0% to 12.5% in intervention groups, with low quality of evidence. Only one non-mortality adverse event was reported across all participants in all studies (a minor musculoskeletal injury), and the quality of the evidence was low. AUTHORS' CONCLUSIONS At this time, we are unable to determine an overall effect on functional exercise capacity, or on health-related quality of life, of an exercise-based intervention initiated after ICU discharge for survivors of critical illness. Meta-analysis of findings was not appropriate because the number of studies and the quantity of data were insufficient. Individual study findings were inconsistent. Some studies reported a beneficial effect of the intervention on functional exercise capacity, and others did not. No effect on health-related quality of life was reported. Methodological rigour was lacking across several domains, influencing the quality of the evidence. Wide variability was noted in the characteristics of interventions, outcome measures and associated metrics and data reporting.If further trials are identified, we may be able to determine the effects of exercise-based intervention following ICU discharge on functional exercise capacity and health-related quality of life among survivors of critical illness.
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Affiliation(s)
- Bronwen Connolly
- Guy's and St Thomas' NHS Foundation TrustLane Fox Clinical Respiratory Physiology Research UnitLondonUK
- King’s College LondonDivision of Asthma, Allergy and Lung BiologyLondonUK
- Guy’s & St Thomas’ NHS Foundation Trust and King’s College London, National Institute of Health Research Biomedical Research CentreLondonUK
| | - Lisa Salisbury
- University of EdinburghEdinburgh Critical Care Research Group MRC Centre for Inflammation ResearchEdinburghUK
| | - Brenda O'Neill
- Ulster UniversityCentre for Health and Rehabilitation Technologies (CHaRT), Institute of Nursing and Health ResearchNewtownabbeyNorthern IrelandUK
| | | | - Abdel Douiri
- Guy’s & St Thomas’ NHS Foundation Trust and King’s College London, National Institute of Health Research Biomedical Research CentreLondonUK
- King's College LondonDepartment of Public Health Sciences, Division of Health and Social Care Research42 Weston StreetLondonUKSE1 3QD
| | - Michael PW Grocott
- University of SouthamptonIntegrative Physiology and Critical Illness Group, Clinical and Experimental SciencesSouthamptonUK
- Southampton NIHR Respiratory Biomedical Research UnitCritical Care Research AreaSouthamptonUK
- University Hospital Southampton NHS Foundation TrustAnaesthesia and Critical Care Research UnitSouthamptonUK
| | - Nicholas Hart
- Guy's and St Thomas' NHS Foundation TrustLane Fox Clinical Respiratory Physiology Research UnitLondonUK
- King’s College LondonDivision of Asthma, Allergy and Lung BiologyLondonUK
- Guy’s & St Thomas’ NHS Foundation Trust and King’s College London, National Institute of Health Research Biomedical Research CentreLondonUK
| | - Timothy S Walsh
- Edinburgh Royal InfirmaryLittle France CrescentEdinburghUKEH16 2SA
| | - Bronagh Blackwood
- Queen’s University BelfastHealth Sciences, School of Medicine, Dentistry and Biomedical Sciences, Centre for Infection and ImmunityBelfastUK
| | - for the ERACIP Group
- The Intensive Care FoundationThe Intensive Care Society, Churchill House35 Red Lion SquareLondonUKWC1R 4SG
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Kim Y, Hong SJ. Intensive Care Unit Delirium. Korean J Crit Care Med 2015. [DOI: 10.4266/kjccm.2015.30.2.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Barriers to early mobility of hospitalized general medicine patients: survey development and results. Am J Phys Med Rehabil 2015; 94:304-12. [PMID: 25133615 DOI: 10.1097/phm.0000000000000185] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Functional status decline commonly accompanies hospitalization making patients vulnerable to complications. Such decline can be mitigated through hospital-based early mobility programs. Success in implementing patient mobility quality improvement processes requires evaluating providers' knowledge, attitudes, and behaviors. DESIGN A cross-sectional, self-administered survey in two different hospital settings was completed by 120 nurses and physical and occupational therapists (rehabilitation therapists, 38; nurses, 82) from six general medicine units. The survey was developed using published guidelines, literature review, and provider meetings and refined through pilot testing. Psychometric properties were assessed, and regression analyses were conducted to examine barriers to early mobility by hospital site, provider discipline, and years of experience. RESULTS Internal consistency reliability, item consistency, and discriminant validity psychometric characteristics were acceptable. In multivariable regression analysis, overall perceived barriers were similar between the two hospitals (P = 0.25) and significantly higher for staff with less experience (P = 0.02) and for nurses vs. rehabilitation therapists (P < 0.001).The survey identified specific barriers common to both nurses and rehabilitation therapists and other barriers that were discipline specific. CONCLUSIONS This novel survey identified important barriers to mobilizing medical inpatients that were similar across two hospital settings. These results can assist with the implementation of quality improvement projects for increasing early hospital-based patient mobility.
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Choong K, Al-Harbi S, Siu K, Wong K, Cheng J, Baird B, Pogorzelski D, Timmons B, Gorter JW, Thabane L, Khetani M. Functional recovery following critical illness in children: the "wee-cover" pilot study. Pediatr Crit Care Med 2015; 16:310-8. [PMID: 25651047 PMCID: PMC4499478 DOI: 10.1097/pcc.0000000000000362] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the feasibility of conducting a longitudinal prospective study to evaluate functional recovery and predictors of impaired functional recovery in critically ill children. DESIGN Prospective pilot study. SETTING Single-center PICU at McMaster Children's Hospital, Hamilton, Canada. PATIENTS Children aged 12 months to 17 years, with at least one organ dysfunction, limited mobility or bed rest during the first 48 hours of PICU admission, and a minimum 48-hour PICU length of stay, were eligible. Patients transferred from a neonatal ICU prior to ever being discharged home, already mobilizing well or at baseline functional status at time of screening, with an English language barrier, and prior enrollment into this study, were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was feasibility, as defined by the ability to screen, enroll eligible patients, and execute the study procedures and measurements on participants. Secondary outcomes included functional status at baseline, 3 and 6 months, PICU morbidity, and mortality. Functional status was measured using the Pediatric Evaluation of Disability Inventory and the Participation and Environment Measure for Children and Youth. Thirty-three patients were enrolled between October 2012 and April 2013. Consent rate was 85%, and follow-up rates were 93% at 3 months and 71% at 6 months. We were able to execute the study procedures and measurements, demonstrating feasibility of conducting a future longitudinal study. Functional status deteriorated following critical illness. Recovery appears to be influenced by baseline health or functional status and severity of illness. CONCLUSION Longitudinal research is needed to understand how children recover after a critical illness. Our results suggest factors that may influence the recovery trajectory and were used to inform the methodology, outcomes of interest, and appropriate sample size of a larger multicenter study evaluating functional recovery in this population.
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Affiliation(s)
- Karen Choong
- 1Department of Pediatrics, Critical Care, Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. 2Division of Pediatric Critical Care, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada. 3Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada. 4Department of Pediatrics, and Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada. 5CanChild Centre for Childhood Disability, McMaster University, Hamilton, Ontario, Canada. 6Department of Occupational Therapy, Colorado State University, Fort Collins, CO
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Karnatovskaia LV, Johnson MM, Benzo RP, Gajic O. The spectrum of psychocognitive morbidity in the critically ill: A review of the literature and call for improvement. J Crit Care 2015; 30:130-7. [DOI: 10.1016/j.jcrc.2014.09.024] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 09/07/2014] [Accepted: 09/29/2014] [Indexed: 10/24/2022]
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Cognitive function, mental health, and health-related quality of life after lung transplantation. Ann Am Thorac Soc 2015; 11:522-30. [PMID: 24605992 DOI: 10.1513/annalsats.201311-388oc] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
RATIONALE Cognitive and psychiatric impairments are threats to functional independence, general health, and quality of life. Evidence regarding these outcomes after lung transplantation is limited. OBJECTIVES Determine the frequency of cognitive and psychiatric impairment after lung transplantation and identify potential factors associated with cognitive impairment after lung transplantation. METHODS In a retrospective cohort study, we assessed cognitive function, mental health, and health-related quality of life using a validated battery of standardized tests in 42 subjects post-transplantation. The battery assessed cognition, depression, anxiety, resilience, and post-traumatic stress disorder (PTSD). Cognitive function was assessed using the Montreal Cognitive Assessment, a validated screening test with a range of 0 to 30. We hypothesized that cognitive function post-transplantation would be associated with type of transplant, cardiopulmonary bypass, primary graft dysfunction, allograft ischemic time, and physical therapy post-transplantation. We used multivariable linear regression to examine the relationship between candidate risk factors and cognitive function post-transplantation. MEASUREMENTS AND MAIN RESULTS Mild cognitive impairment (score, 18-25) was observed in 67% of post-transplant subjects (95% confidence interval [CI]: 50-80%) and moderate cognitive impairment (score, 10-17) was observed in 5% (95% CI, 1-16%) of post-transplant subjects. Symptoms of moderate to severe anxiety and depression were observed in 21 and 3% of post-transplant subjects, respectively. No transplant recipients reported symptoms of PTSD. Higher resilience correlated with less psychological distress in the domains of depression (P < 0.001) and PTSD (P = 0.02). Prolonged graft ischemic time was independently associated with worse cognitive performance after lung transplantation (P = 0.001). The functional gain in 6-minute-walk distance achieved at the end of post-transplant physical rehabilitation (P = 0.04) was independently associated with improved cognitive performance post-transplantation. CONCLUSIONS Mild cognitive impairment was present in the majority of patients after lung transplantation. Prolonged allograft ischemic time may be associated with cognitive impairment. Poor physical performance and cognitive impairment are linked, and physical rehabilitation post-transplant and psychological resilience may be protective against the development of long-term impairment. Further study is warranted to confirm these potential associations and to examine the trajectory of cognitive function after lung transplantation.
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