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Stewart J, Bradley J, Smith S, McPeake J, Walsh T, Haines K, Leggett N, Hart N, McAuley D. Do critical illness survivors with multimorbidity need a different model of care? Crit Care 2023; 27:485. [PMID: 38066562 PMCID: PMC10709866 DOI: 10.1186/s13054-023-04770-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023] Open
Abstract
There is currently a lack of evidence on the optimal strategy to support patient recovery after critical illness. Previous research has largely focussed on rehabilitation interventions which aimed to address physical, psychological, and cognitive functional sequelae, the majority of which have failed to demonstrate benefit for the selected outcomes in clinical trials. It is increasingly recognised that a person's existing health status, and in particular multimorbidity (usually defined as two or more medical conditions) and frailty, are strongly associated with their long-term outcomes after critical illness. Recent evidence indicates the existence of a distinct subgroup of critical illness survivors with multimorbidity and high healthcare utilisation, whose prior health trajectory is a better predictor of long-term outcomes than the severity of their acute illness. This review examines the complex relationships between multimorbidity and patient outcomes after critical illness, which are likely mediated by a range of factors including the number, severity, and modifiability of a person's medical conditions, as well as related factors including treatment burden, functional status, healthcare delivery, and social support. We explore potential strategies to optimise patient recovery after critical illness in the presence of multimorbidity. A comprehensive and individualized approach is likely necessary including close coordination among healthcare providers, medication reconciliation and management, and addressing the physical, psychological, and social aspects of recovery. Providing patient-centred care that proactively identifies critical illness survivors with multimorbidity and accounts for their unique challenges and needs is likely crucial to facilitate recovery and improve outcomes.
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Affiliation(s)
- Jonathan Stewart
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland.
| | - Judy Bradley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
| | - Susan Smith
- Department of Public Health and Primary Care, Trinity College Dublin, Dublin 2, Ireland
| | - Joanne McPeake
- The Healthcare Improvement Studies Institute, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Timothy Walsh
- Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Kimberley Haines
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Nina Leggett
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Nigel Hart
- Centre for Medical Education, Queen's University Belfast, Belfast, Northern Ireland
| | - Danny McAuley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
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Parotto M, Gyöngyösi M, Howe K, Myatra SN, Ranzani O, Shankar-Hari M, Herridge MS. Post-acute sequelae of COVID-19: understanding and addressing the burden of multisystem manifestations. THE LANCET. RESPIRATORY MEDICINE 2023:S2213-2600(23)00239-4. [PMID: 37475125 DOI: 10.1016/s2213-2600(23)00239-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/22/2023]
Abstract
Individuals with SARS-CoV-2 infection can develop symptoms that persist well beyond the acute phase of COVID-19 or emerge after the acute phase, lasting for weeks or months after the initial acute illness. The post-acute sequelae of COVID-19, which include physical, cognitive, and mental health impairments, are known collectively as long COVID or post-COVID-19 condition. The substantial burden of this multisystem condition is felt at individual, health-care system, and socioeconomic levels, on an unprecedented scale. Survivors of COVID-19-related critical illness are at risk of the well known sequelae of acute respiratory distress syndrome, sepsis, and chronic critical illness, and these multidimensional morbidities might be difficult to differentiate from the specific effects of SARS-CoV-2 and COVID-19. We provide an overview of the manifestations of post-COVID-19 condition after critical illness in adults. We explore the effects on various organ systems, describe potential pathophysiological mechanisms, and consider the challenges of providing clinical care and support for survivors of critical illness with multisystem manifestations. Research is needed to reduce the incidence of post-acute sequelae of COVID-19-related critical illness and to optimise therapeutic and rehabilitative care and support for patients.
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Affiliation(s)
- Matteo Parotto
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, ON, Canada; Department of Anesthesia and Pain Medicine, Toronto General Hospital, Toronto, ON, Canada.
| | - Mariann Gyöngyösi
- Division of Cardiology, 2nd Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Kathryn Howe
- Division of Vascular Surgery, University Health Network, Toronto, ON, Canada
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Otavio Ranzani
- Barcelona Institute for Global Health, ISGlobal, Barcelona, Spain; Pulmonary Division, Heart Institute, Faculty of Medicine, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Manu Shankar-Hari
- The Queen's Medical Research Institute, Edinburgh BioQuarter, Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Margaret S Herridge
- Department of Medicine, University of Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada
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Piva S, Pozzi M, Bellani G, Peli E, Gitti N, Lucchini A, Bertoni M, Goffi A, Marshall JC, Calza S, Rasulo FA, Foti G, Latronico N. Long-term physical impairments in survivors of COVID-19-associated ARDS compared with classic ARDS: A two-center study. J Crit Care 2023; 76:154285. [PMID: 36889040 DOI: 10.1016/j.jcrc.2023.154285] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 01/22/2023] [Accepted: 02/25/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE This work aimed to compare physical impairment in survivors of classic ARDS compared with COVID-19-associated ARDS (CARDS) survivors. MATERIAL AND METHODS This is a prospective observational cohort study on 248 patients with CARDS and compared them with a historical cohort of 48 patients with classic ARDS. Physical performance was evaluated at 6 and 12 months after ICU discharge, using the Medical Research Council Scale (MRCss), 6-min walk test (6MWT), handgrip dynamometry (HGD), and fatigue severity score (FSS). We also assessed activities of daily living (ADLs) using the Barthel index. RESULTS At 6 months, patients with classic ARDS had lower HGD (estimated difference [ED]: 11.71 kg, p < 0.001; ED 31.9% of predicted value, p < 0.001), 6MWT distance (ED: 89.11 m, p < 0.001; ED 12.96% of predicted value, p = 0.032), and more frequent significant fatigue (OR 0.35, p = 0.046). At 12 months, patients with classic ARDS had lower HGD (ED: 9.08 kg, p = 0.0014; ED 25.9% of predicted value, p < 0.001) and no difference in terms of 6MWT and fatigue. At 12 months, patients with classic ARDS improved their MRCss (ED 2.50, p = 0.006) and HGD (ED: 4.13 kg, p = 0.002; ED 9.45% of predicted value, p = 0.005), while those with CARDS did not. Most patients in both groups regained independence in ADLs at 6 months. COVID-19 diagnosis was a significant independent predictor of better HGD (p < 0.0001) and 6MWT performance (p = 0.001), and lower prevalence of fatigue (p = 0.018). CONCLUSIONS Both classic ARDS and CARDS survivors experienced long-term impairments in physical functioning, confirming that post-intensive care syndrome remains a major legacy of critical illness. Surprisingly, however, persisting disability was more common in survivors of classic ARDS than in CARDS survivors. In fact, muscle strength measured with HGD was reduced in survivors of classic ARDS compared to CARDS patients at both 6 and 12 months. The 6MWT was reduced and fatigue was more common in classic ARDS compared to CARDS at 6 months but differences were no longer significant at 12 months. Most patients in both groups regained independent function in ADLs at 6 months.
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Affiliation(s)
- Simone Piva
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy; Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy.
| | - Matteo Pozzi
- Department of Emergency and Intensive Care, ASST Monza, Monza, Italy
| | - Giacomo Bellani
- Department of Emergency and Intensive Care, ASST Monza, Monza, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Elena Peli
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Nicola Gitti
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy; Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Alberto Lucchini
- Department of Emergency and Intensive Care, ASST Monza, Monza, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John C Marshall
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, Unity Health Toronto, University of Toronto, Toronto, ON, Canada
| | - Stefano Calza
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Francesco A Rasulo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy; Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Giuseppe Foti
- Department of Emergency and Intensive Care, ASST Monza, Monza, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy; Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
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van Beinum A. Challenging the logic of lifesaving in the intensive care unit. Soc Sci Med 2023; 321:115769. [PMID: 36809699 DOI: 10.1016/j.socscimed.2023.115769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/17/2023] [Accepted: 02/10/2023] [Indexed: 02/19/2023]
Abstract
Intensive care units are considered life-saving medical services and a vital component of healthcare systems. These specialized hospital wards contain the life support machines and technical expertise to sustain seriously ill and injured bodies. However, as the COVID-19 pandemic has demonstrated, intensive care is an expensive, finite resource which is not necessarily available to all citizens, and which may be unjustly rationed. As a result, the intensive care unit may contribute more towards biopolitical narratives of investment in lifesaving than measurable improvements in population health. Drawing from ethnographic fieldwork and a decade of involvement in clinical research, this paper examines everyday activities of lifesaving in the intensive care unit and interrogates epistemological assumptions upon which they are organized. A closer look at how healthcare professionals, medical devices, patients, and families accept, refuse, and modify imposed boundaries of bodily finitude reveals how activities of lifesaving often lead to uncertainty and may even impose harm when they deny possibilities for desired death. Refiguring death as a personal ethical threshold, rather than inherently tragic ending, challenges the power of the logic of lifesaving and instead insists on greater attention towards improving conditions for living.
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Affiliation(s)
- Amanda van Beinum
- Department of Sociology and Anthropology, Carleton University, Ottawa, Ontario, Canada; Centre for Health Law, Policy and Ethics, University of Ottawa, Ottawa, Ontario, Canada.
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Killien EY, Maddux AB, Tse SM, Watson RS. Outcomes of Children Surviving Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S28-S44. [PMID: 36661434 PMCID: PMC9869462 DOI: 10.1097/pcc.0000000000003157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To summarize the evidence for the Second Pediatric Acute Lung Injury Consensus Conference-2 (PALICC-2) recommendations for assessment of outcomes among patients surviving pediatric acute respiratory distress syndrome (PARDS). DATA SOURCES MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION We conducted a scoping review to identify studies evaluating outcomes following PARDS. We included studies of survivors of PARDS, acute respiratory failure with a high proportion of PARDS patients, or other critical illnesses if PARDS-specific outcomes could be extracted. DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize evidence and develop recommendations. Of 8,037 abstracts screened, we identified 20 articles for inclusion. Morbidity following PARDS was common and affected multiple domains of pulmonary and nonpulmonary function. There was insufficient evidence to generate any evidence-based recommendations. We generated eight good practice statements and five research statements. A panel of 52 experts discussed each proposed good practice statement and research statement, and the agreement rate was measured with an online voting process. Good practice statements describe the approach to clinical outcome assessment, assessment of pulmonary outcomes of children surviving PARDS, and assessment of nonpulmonary outcomes of children surviving PARDS including health-related quality of life and physical, neurocognitive, emotional, family, and social functioning. The five research statements relate to assessment of patient preillness status, use of postdischarge endpoints for clinical trials, the association between short-term and longer term outcomes, the trajectory of recovery following PARDS, and practices to optimize follow-up. CONCLUSIONS There is increasing evidence that children are at risk for impairments across a range of pulmonary and nonpulmonary health domains following hospitalization for PARDS. The results of this extensive scoping review and consensus conference involving experts in PARDS research, clinical care, and outcomes assessment provide guidance to clinicians and researchers on postdischarge follow-up to optimize the long-term health of patients surviving PARDS.
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Affiliation(s)
- Elizabeth Y. Killien
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA
| | - Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Sze Man Tse
- Department of Pediatrics, University of Montréal, Montréal, Canada
- Division of Respiratory Medicine, Department of Pediatrics, Sainte-Justine University Hospital Center, Montréal, Québec, Canada
| | - R. Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA
- Center for Child Health, Behavior, & Development, Seattle Children’s Research Institute, Seattle, WA
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Maddux AB, Mourani PM, Miller K, Carpenter TC, LaVelle J, Pyle LL, Watson RS, Bennett TD. Identifying Long-Term Morbidities and Health Trajectories After Prolonged Mechanical Ventilation in Children Using State All Payer Claims Data. Pediatr Crit Care Med 2022; 23:e189-e198. [PMID: 35250002 PMCID: PMC9058185 DOI: 10.1097/pcc.0000000000002909] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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
OBJECTIVES To identify postdischarge outcome phenotypes and risk factors for poor outcomes using insurance claims data. DESIGN Retrospective cohort study. SETTING Single quaternary center. PATIENTS Children without preexisting tracheostomy who required greater than or equal to 3 days of invasive mechanical ventilation, survived the hospitalization, and had postdischarge insurance eligibility in Colorado's All Payer Claims Database. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We used unsupervised machine learning to identify functional outcome phenotypes based on claims data representative of postdischarge morbidities. We assessed health trajectory by comparing change in the number of insurance claims between quarters 1 and 4 of the postdischarge year. Regression analyses identified variables associated with unfavorable outcomes. The 381 subjects had median age 3.3 years (interquartile range, 0.9-12 yr), and 147 (39%) had a complex chronic condition. Primary diagnoses were respiratory (41%), injury (23%), and neurologic (11%). We identified three phenotypes: lower morbidity (n = 300), higher morbidity (n = 62), and 1-year nonsurvivors (n = 19). Complex chronic conditions most strongly predicted the nonsurvivor phenotype. Longer PICU stays and tracheostomy placement most strongly predicted the higher morbidity phenotype. Patients with high but improving postdischarge resource use were differentiated by high illness severity and long PICU stays. Patients with persistently high or increasing resource use were differentiated by complex chronic conditions and tracheostomy placement. CONCLUSIONS New morbidities are common after prolonged mechanical ventilation. Identifying phenotypes at high risk of postdischarge morbidity may facilitate prognostic enrichment in clinical trials.
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Affiliation(s)
- Aline B. Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care, University of Arkansas for Medical Sciences and Arkansas Children’s, Little Rock, AR
| | - Kristen Miller
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Todd C. Carpenter
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | | | - Laura L. Pyle
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
- Department of Biostatistics and Informatics, Colorado School of Public Health, Children’s Hospital Colorado, Aurora, CO
| | - R. Scott Watson
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington School of Medicine and Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA
| | - Tellen D. Bennett
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
- Department of Pediatrics, Section of Informatics and Data Science, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO
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Why and how do we need comprehensive international clinical epidemiology of ARDS? Intensive Care Med 2021; 47:1014-1016. [PMID: 34216223 PMCID: PMC8254436 DOI: 10.1007/s00134-021-06469-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/26/2021] [Indexed: 11/20/2022]
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Maddux AB, Sevick C, Cox-Martin M, Bennett TD. Novel Claims-Based Outcome Phenotypes in Survivors of Pediatric Traumatic Brain Injury. J Head Trauma Rehabil 2021; 36:242-252. [PMID: 33656469 PMCID: PMC8249306 DOI: 10.1097/htr.0000000000000646] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE For children hospitalized with acute traumatic brain injury (TBI), to use postdischarge insurance claims to identify: (1) healthcare utilization patterns representative of functional outcome phenotypes and (2) patient and hospitalization characteristics that predict outcome phenotype. SETTING Two pediatric trauma centers and a state-level insurance claim aggregator. PATIENTS A total of 289 children, who survived a hospitalization after TBI between 2009 and 2014, were in the hospital trauma registry, and had postdischarge insurance eligibility. DESIGN Retrospective cohort study. MAIN MEASURES Unsupervised machine learning to identify phenotypes based on postdischarge insurance claims. Regression analyses to identify predictors of phenotype. RESULTS Median age 5 years (interquartile range 2-12), 29% (84/289) female. TBI severity: 30% severe, 14% moderate, and 60% mild. We identified 4 functional outcome phenotypes. Phenotypes 3 and 4 were the highest utilizers of resources. Morbidity burden was highest during the first 4 postdischarge months and subsequently decreased in all domains except respiratory. Severity and mechanism of injury, intracranial pressure monitor placement, seizures, and hospital and intensive care unit lengths of stay were phenotype predictors. CONCLUSIONS Unsupervised machine learning identified postdischarge phenotypes at high risk for morbidities. Most phenotype predictors are available early in the hospitalization and can be used for prognostic enrichment of clinical trials targeting mitigation or treatment of domain-specific morbidities.
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Affiliation(s)
- Aline B. Maddux
- Assistant Professor of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Carter Sevick
- Data Analyst, Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children’s Hospital Colorado, Aurora, Colorado
| | - Matthew Cox-Martin
- Data Analyst, Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and Children’s Hospital Colorado, Aurora, Colorado
| | - Tellen D. Bennett
- Associate Professor and Section Head, Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO
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Kean S, Donaghy E, Bancroft A, Clegg G, Rodgers S. Theorising survivorship after intensive care: A systematic review of patient and family experiences. J Clin Nurs 2021; 30:2584-2610. [PMID: 33829568 DOI: 10.1111/jocn.15766] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 02/26/2021] [Accepted: 03/01/2021] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVE This systematic literature review explores and maps what we know about survivorship to understand how survivorship can be theoretically defined. BACKGROUND Survivorship of critical illness has been identified as a challenge for the 21st Century. Whilst the use of the term 'survivorship' is now common in critical care, it has been borrowed from the cancer literature where the discourse on what survivorship means in a cancer context is ongoing and remains largely descriptive. In the absence of a theoretical understanding, the term 'survivorship' is often used in critical illness in a generic way, limiting our understanding of what survivorship is. The current COVID-19 pandemic adds to an urgency of understanding what intensive care unit (ICU) survivorship might mean, given the emerging long-term consequences of this patient cohort. We set out to explore how survivorship after critical illness is being conceptualised and what the implications might be for clinical practice and research. DESIGN Integrated systematic literature review. The review protocol was registered with PROSPERO International Prospective Register of Systematic Reviews. PRISMA guidelines were followed and a PRISMA checklist for reporting systematic reviews completed. RESULTS The three main themes around which the reviewed studies were organised are: (a) healthcare system; (b) ICU survivors' families; and (c) ICU survivor's identity. These three themes feed into an overarching core theme of 'ICU Survivorship Experiences'. These themes map our current knowledge of what happens when a patient survives a critical illness and where we are in understanding ICU survivorship. CONCLUSION We mapped in this systematic review the different pieces of the jigsaw that emerge following critical illness to understand and see the bigger picture of what happens after patients survive critical illness. It is evident that existing research has mapped these connections, but what we have not managed to do yet is defining what survivorship is theoretically. We offer a preliminary definition of survivorship as a process but are aware that this definition needs to be developed further with patients and families.
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Affiliation(s)
- Susanne Kean
- Nursing Studies, School of Health in Social Science, The University of Edinburgh, Edinburgh, UK
| | - Eddie Donaghy
- Usher Institute of Population Health Sciences and Informatics & Edinburgh Critical Care Research Group, The University of Edinburgh, Edinburgh, UK
| | - Angus Bancroft
- School of Social and Political Science, University of Edinburgh, Edinburgh, UK
| | - Gareth Clegg
- Deanery of Clinical Sciences, Centre for Inflammation Research, Edinburgh BioQuarter, University of Edinburgh, Edinburgh, UK
| | - Sheila Rodgers
- Nursing Studies, School of Health in Social Science, The University of Edinburgh, Edinburgh, UK
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10
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Spontaneous Versus Controlled Mechanical Ventilation in Patients with Acute Respiratory Distress Syndrome. CURRENT ANESTHESIOLOGY REPORTS 2021; 11:85-91. [PMID: 33679255 PMCID: PMC7925253 DOI: 10.1007/s40140-021-00443-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 01/06/2023]
Abstract
Purpose of Review To review clinical evidence on whether or not to allow mechanically ventilated patients with acute respiratory distress syndrome (ARDS) to breathe spontaneously. Recent Findings Observational data (LUNG SAFE study) indicate that mechanical ventilation allowing for spontaneous breathing (SB) is associated with more ventilator-free days and a shorter stay in the intensive care unit without any effect on hospital mortality. A paediatric trial, comparing airway pressure release ventilation (APRV) and low-tidal volume ventilation, showed an increase in mortality in the APRV group. Conversely, in an unpublished trial comparing SB and controlled ventilation (NCT01862016), the authors concluded that SB is feasible but did not improve outcomes in ARDS patients. Summary A paucity of clinical trial data continues to prevent firm guidance on if or when to allow SB during mechanical ventilation in patients with ARDS. No published large randomised controlled trial exists to inform practice about the benefits and harms of either mode.
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Abstract
The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has caused the Coronavirus Disease 2019 (COVID-19) worldwide pandemic in 2020. In response, most countries in the world implemented lockdowns, restricting their population's movements, work, education, gatherings, and general activities in attempt to "flatten the curve" of COVID-19 cases. The public health goal of lockdowns was to save the population from COVID-19 cases and deaths, and to prevent overwhelming health care systems with COVID-19 patients. In this narrative review I explain why I changed my mind about supporting lockdowns. The initial modeling predictions induced fear and crowd-effects (i.e., groupthink). Over time, important information emerged relevant to the modeling, including the lower infection fatality rate (median 0.23%), clarification of high-risk groups (specifically, those 70 years of age and older), lower herd immunity thresholds (likely 20-40% population immunity), and the difficult exit strategies. In addition, information emerged on significant collateral damage due to the response to the pandemic, adversely affecting many millions of people with poverty, food insecurity, loneliness, unemployment, school closures, and interrupted healthcare. Raw numbers of COVID-19 cases and deaths were difficult to interpret, and may be tempered by information placing the number of COVID-19 deaths in proper context and perspective relative to background rates. Considering this information, a cost-benefit analysis of the response to COVID-19 finds that lockdowns are far more harmful to public health (at least 5-10 times so in terms of wellbeing years) than COVID-19 can be. Controversies and objections about the main points made are considered and addressed. Progress in the response to COVID-19 depends on considering the trade-offs discussed here that determine the wellbeing of populations. I close with some suggestions for moving forward, including focused protection of those truly at high risk, opening of schools, and building back better with a economy.
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Affiliation(s)
- Ari R. Joffe
- Division of Critical Care Medicine, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
- John Dossetor Health Ethics Center, University of Alberta, Edmonton, AB, Canada
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12
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Truffaut L, Demey L, Bruyneel AV, Roman A, Alard S, De Vos N, Bruyneel M. Post-discharge critical COVID-19 lung function related to severity of radiologic lung involvement at admission. Respir Res 2021; 22:29. [PMID: 33478527 PMCID: PMC7819622 DOI: 10.1186/s12931-021-01625-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/14/2021] [Indexed: 02/06/2023] Open
Abstract
Lung function impairment persists in 55% of critical COVID-19 patients three months after ICU discharge. Patient lung function, exercise capacity, radiologic, and quality of life data suggest impairment is related to radiologic lung involvement at admission.
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Affiliation(s)
- Laurent Truffaut
- Department of Pneumology, CHU Saint-Pierre, Brussels, Belgium.,Université Libre de Bruxelles, Brussels, Belgium
| | - Lucas Demey
- Department of Pneumology, CHU Saint-Pierre, Brussels, Belgium.,Université Libre de Bruxelles, Brussels, Belgium
| | | | - Alain Roman
- Department of Intensive Care Medicine, CHU Saint-Pierre, Brussels, Belgium.,Université Libre de Bruxelles, Brussels, Belgium
| | - Stephane Alard
- Department of Radiology, CHU Saint-Pierre, Brussels, Belgium.,Université Libre de Bruxelles, Brussels, Belgium
| | - Nathalie De Vos
- Department of Clinical Chemistry, LHUB-ULB, Université Libre de Bruxelles, Brussels, Belgium
| | - Marie Bruyneel
- Department of Pneumology, CHU Saint-Pierre, Brussels, Belgium. .,Université Libre de Bruxelles, Brussels, Belgium.
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13
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Liang M, He M, Tang J, He X, Liu Z, Feng S, Chen P, Li H, Xue Y, Bai T, Ma Y, Zhang J. Novel risk scoring system for predicting acute respiratory distress syndrome among hospitalized patients with coronavirus disease 2019 in Wuhan, China. BMC Infect Dis 2020; 20:960. [PMID: 33334314 PMCID: PMC7744733 DOI: 10.1186/s12879-020-05561-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 10/30/2020] [Indexed: 01/08/2023] Open
Abstract
Background The mortality rate from acute respiratory distress syndrome (ARDS) is high among hospitalized patients with coronavirus disease 2019 (COVID-19). Hence, risk evaluation tools are required to immediately identify high-risk patients upon admission for early intervention. Methods A cohort of 220 consecutive patients with COVID-19 were included in this study. To analyze the risk factors of ARDS, data obtained from approximately 70% of the participants were randomly selected and used as training dataset to establish a logistic regression model. Meanwhile, data obtained from the remaining 30% of the participants were used as test dataset to validate the effect of the model. Results Lactate dehydrogenase, blood urea nitrogen, D-dimer, procalcitonin, and ferritin levels were included in the risk score system and were assigned a score of 25, 15, 34, 20, and 24, respectively. The cutoff value for the total score was > 35, with a sensitivity of 100.00% and specificity of 81.20%. The area under the receiver operating characteristic curve and the Hosmer–Lemeshow test were 0.967 (95% confidence interval [CI]: 0.925–0.989) and 0.437(P Value = 0.437). The model had excellent discrimination and calibration during internal validation. Conclusions The novel risk score may be a valuable risk evaluation tool for screening patients with COVID-19 who are at high risk of ARDS. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-020-05561-y.
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Affiliation(s)
- Mengyuan Liang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China
| | - Miao He
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China
| | - Jian Tang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China
| | - Xinliang He
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China
| | - Zhijun Liu
- Department of Neurology, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China
| | - Siwei Feng
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China
| | - Ping Chen
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China
| | - Hui Li
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China
| | - Yu'e Xue
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China
| | - Tao Bai
- Department of Gastroenterology, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China
| | - Yanling Ma
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China.
| | - Jianchu Zhang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical Collage, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, Hubei Province, China.
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14
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Kamuf J, Garcia Bardon A, Ziebart A, Frauenknecht K, Folkert K, Schwab J, Ruemmler R, Renz M, Cana D, Thal SC, Hartmann EK. Experimental lung injury induces cerebral cytokine mRNA production in pigs. PeerJ 2020; 8:e10471. [PMID: 33354426 PMCID: PMC7733330 DOI: 10.7717/peerj.10471] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 11/11/2020] [Indexed: 12/02/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is an important disease with a high incidence among patients admitted to intensive care units. Over the last decades, the survival of critically ill patients has improved; however, cognitive deficits are among the long-term sequelae. We hypothesize that acute lung injury leads to upregulation of cerebral cytokine synthesis. Methods After approval of the institutional and animal care committee, 20 male pigs were randomized to one of three groups: (1) Lung injury by oleic acid injection (OAI), (2) ventilation only (CTR) or (3) untreated. We compared neuronal numbers, proportion of neurons with markers for apoptosis, activation state of Iba-1 stained microglia cells and cerebral mRNA levels of different cytokines between the groups 18 hours after onset of lung injury. Results We found an increase in hippocampal TNFalpha (p < 0.05) and IL-6 (p < 0.05) messenger RNA (mRNA) in the OAI compared to untreated group as well as higher hippocampal IL-6 mRNA compared to control (p < 0.05). IL-8 and IL-1beta mRNA showed no differences between the groups. We found histologic markers for beginning apoptosis in OAI compared to untreated (p < 0.05) and more active microglia cells in OAI and CTR compared to untreated (p < 0.001 each). Conclusion Hippocampal cytokine transcription increases within 18 hours after the induction of acute lung injury with histological evidence of neuronal damage. It remains to be elucidated if increased cytokine mRNA synthesis plays a role in the cognitive decline observed in survivors of ARDS.
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Affiliation(s)
- Jens Kamuf
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Andreas Garcia Bardon
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Alexander Ziebart
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Katrin Frauenknecht
- Institute of Neuropathology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Konstantin Folkert
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Johannes Schwab
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Robert Ruemmler
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Miriam Renz
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Denis Cana
- Institute of Neuropathology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Serge C Thal
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Erik K Hartmann
- Department of Anesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
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15
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The experiences and needs of relatives of intensive care unit patients during the transition from the intensive care unit to a general ward: A qualitative study. Aust Crit Care 2020; 33:526-532. [DOI: 10.1016/j.aucc.2020.01.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 01/06/2020] [Accepted: 01/09/2020] [Indexed: 11/23/2022] Open
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16
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Laxe S, Ferri J, Juárez-Belaunde A, Ríos-Lago M, Rodríguez-Duarte R, Murie-Fernández M. Neurorehabilitation in the times of Covid-19: insights from the Spanish Neurorehabilitation Society (SENR). Brain Inj 2020; 34:1691-1692. [PMID: 33104386 DOI: 10.1080/02699052.2020.1830172] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The entire world is experiencing an unprecedented global health crisis and Spain has been one of the most heavily affected countries within Europe. Unexpected rapid changes and reorganization of medical services that occurred during the pandemic lead to an impact in the practice of neurorehabilitation. The idiosyncrasies typical of neurorehabilitation management, specially in acute facilities, that makes it susceptible as a vector of dissemination of Covid but also because of the need of finding new wards and intensive care units for Covid patients, the interventions in neurorehabilitation has suffered enormous changes. There is a need for rethinking the future to treat a new wave of patients with neurorehabilitation necessities such as those recovering from Covid 19 with neurological sequelae but also of those neurorehab patients who were unable to access the health system during the locke down period. This article is intended to invite to reflect on and discuss the redesign of our current neurorehabilitation plans after the experience on the Covid 19 pandemic.
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Affiliation(s)
- S Laxe
- Sociedad Española de Neurorrehabilitación (SENR).,Physical Medicine and Rehabilitation Department, ICEMEQ, Hospital Clinic , Barcelona, Spain
| | - J Ferri
- Sociedad Española de Neurorrehabilitación (SENR).,NEURORHB, Neurorehabilitation Department, Vithas Hospital , València, Spain.,Fundación Salud y Cerebro , València, Spain.,Fundación Hospitales Vithas , València, Spain
| | - A Juárez-Belaunde
- Sociedad Española de Neurorrehabilitación (SENR).,Neurorehabilitation Unit Hospital Los Madroños , Madrid, Spain
| | - M Ríos-Lago
- Sociedad Española de Neurorrehabilitación (SENR).,Brain Injury Unit, Hospital Beata María Ana , Madrid, Spain.,Dpto. Psicología Básica, UNED , Madrid, Spain
| | - R Rodríguez-Duarte
- Sociedad Española de Neurorrehabilitación (SENR).,Neurorehabilitation Center Charbel, Jerez De La Frontera , Cádiz, Spain
| | - M Murie-Fernández
- Neurorehabilitation Unit Hospital Ciudad de Telde , Las Palmas De Gran Canaria, Spain
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17
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Canagliflozin alleviates LPS-induced acute lung injury by modulating alveolar macrophage polarization. Int Immunopharmacol 2020; 88:106969. [PMID: 33182027 DOI: 10.1016/j.intimp.2020.106969] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/31/2020] [Accepted: 08/31/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Canagliflozin (CANA), a sodium-glucose cotransporter 2 inhibitor, is a novel therapeutic agent that exhibits multiple actions in type 2 diabetes. CANA can regulate intracellular glucose metabolism and exert anti-inflammatory effects in immune cells. Alveolar macrophage polarization balance is often associated with lower inflammation in acute lung injury (ALI). However, little is known about the anti-inflammatory effect of CANA on ALI. METHODS This study aimed to determine the effect of CANA on ALI as well as its potential ability to modulate alveolar macrophage polarization in ALI mouse models and bone marrow-derived macrophages (BMDMs). RESULTS The histopathological changes indicated that CANA alleviated lung injury in lipopolysaccharide-induced ALI mice models and exerted anti-inflammatory effects in the presence of lower levels of tumor necrosis factor-ɑ, interleukin-6, and interleukin-1β in bronchoalveolar lavage fluid (BALF) and serum. Moreover, flow cytometry analysis of mouse BALF cells and BMDMs demonstrated that CANA can modulate and reconstitute M1 and M2 macrophage balance, inhibiting macrophages with the M1 phenotype while promoting macrophages to shift to the M2 phenotype. Immunohistochemistry and reverse transcription polymerase chain reaction were also performed. CONCLUSIONS These findings indicate that CANA alleviates lung injury and exerts anti-inflammatory effects by modulating alveolar macrophage polarization balance, suggesting that CANA might act as a novel anti-inflammatory drug for treating ALI.
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18
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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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19
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Pourfathi M, Kadlecek SJ, Chatterjee S, Rizi RR. Metabolic Imaging and Biological Assessment: Platforms to Evaluate Acute Lung Injury and Inflammation. Front Physiol 2020; 11:937. [PMID: 32982768 PMCID: PMC7487972 DOI: 10.3389/fphys.2020.00937] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/13/2020] [Indexed: 12/26/2022] Open
Abstract
Pulmonary inflammation is a hallmark of several pulmonary disorders including acute lung injury and acute respiratory distress syndrome. Moreover, it has been shown that patients with hyperinflammatory phenotype have a significantly higher mortality rate. Despite this, current therapeutic approaches focus on managing the injury rather than subsiding the inflammatory burden of the lung. This is because of the lack of appropriate non-invasive biomarkers that can be used clinically to assess pulmonary inflammation. In this review, we discuss two metabolic imaging tools that can be used to non-invasively assess lung inflammation. The first method, Positron Emission Tomography (PET), is widely used in clinical oncology and quantifies flux in metabolic pathways by measuring uptake of a radiolabeled molecule into the cells. The second method, hyperpolarized 13C MRI, is an emerging tool that interrogates the branching points of the metabolic pathways to quantify the fate of metabolites. We discuss the differences and similarities between these techniques and discuss their clinical applications.
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Affiliation(s)
- Mehrdad Pourfathi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States
| | - Stephen J. Kadlecek
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States
| | - Shampa Chatterjee
- Department of Physiology, University of Pennsylvania, Philadelphia, PA, United States
| | - Rahim R. Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States
- *Correspondence: Rahim R. Rizi,
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20
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Khoo TC, Jesudason E, FitzGerald A. Catching our breath: reshaping rehabilitation services for COVID-19. Disabil Rehabil 2020; 43:112-117. [PMID: 32853046 DOI: 10.1080/09638288.2020.1808905] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE War and natural disaster have been spurs to the creation of rehabilitation services. The COVID-19 pandemic poses a different question for existing rehabilitation services: how best to respond to a disaster that is anticipated from afar, but whose shape has yet to take full form? METHODS Applying the 5-phase crisis management model of Pearson and Mitroff, we report our experience at one of Scotland's largest centres for rehabilitation, in planning to cope with COVID-19. RESULTS Contingency rehabilitation planning can be framed in a 5-phase crisis management model that includes (i) signal detection; (ii) prevention/preparedness; (iii) damage limitation; (iv) recovery; and (v) learning. We have reported the impact of COVID-19 on rehabilitation services within a Scottish context and shared some of our learning. CONCLUSION COVID-19 has challenged healthcare worldwide and has served as an amplifier for the recognised ill effects of poverty and inequality. As rehabilitation clinicians, we are in a position to continue advocating for people facing disability, and also seeking and responding to signals of COVID-19's late effects in both COVID-19 and non-COVID-19 patients alike. IMPLICATIONS FOR REHABILITATION COVID-19 has resulted in unprecedented challenges in rehabilitation service planning. Contingency rehabilitation planning can be framed in a 5-phase crisis management model of Pearson and Mitroff, including (i) signal detection; (ii) prevention/preparedness; (iii) damage limitation; (iv) recovery; and (v) learning. COVID-19 has served as an amplifier for the recognised ill effects of poverty and inequality; as rehabilitation clinicians, we are in a position to continue advocating for people facing disability, and also seeking and responding to signals of COVID-19's late effects in both COVID-19 and non-COVID-19 patients alike.
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Affiliation(s)
- Teng Cheng Khoo
- Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, UK
| | - Edwin Jesudason
- Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, UK
| | - Alasdair FitzGerald
- Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, UK
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21
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Shah H, Mansuri U, Pagad S, Adupa R, Singh J, Tun K, Shah C, Tuonuur S, Shah PJ, Ali Khan MZ, Grewal GS, Goswami R, Solanki S. Rate and Modifiable Predictors of 30-Day Readmission in Patients with Acute Respiratory Distress Syndrome in the United States. Cureus 2020; 12:e8922. [PMID: 32760623 PMCID: PMC7392362 DOI: 10.7759/cureus.8922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background The 30-day readmission rates are being used as a quality measure by Centers for Medicare and Medicaid Services (CMS) for specific medical and surgical conditions. Acute respiratory distress syndrome (ARDS) is one of the important causes of morbidity and mortality in the United States (US). The characteristics and predictors of 30-day readmission in ARDS patients in the US are not widely known, which we have depicted in our study. Objective The aim of this study is to identify 30-day readmission rates, characteristics, and predictors of ARDS patients using the largest publicly available nationwide database. Methods We used the National Readmission Database from the year 2013 to extract the patients with ARDS by primary discharge diagnosis with ICD9-CM codes. All-cause unplanned 30-day readmission rates were calculated for patients admitted between January and November 2013. The independent predictors for unplanned 30-day readmission were identified by survey logistic regression. Results After excluding elective readmission, the all-cause unplanned 30-day readmission rate for ARDS patients was 18%. Index admissions readmitted within 30-day had a significantly higher baseline burden of comorbidities with a Charlson Comorbidity Index (CCI) ≥1 as compared to those who were not readmitted within 30 days. In multivariate regression analysis, several predictors associated with 30-day readmission were self-pay/no charge/other (OR 1.19, 95%CI: 1.02-1.38; p = 0.02), higher-income class (OR 0.86, 95%CI:0.79-0.99; p = 0.03), private insurance (OR 0.81, 95%CI:0.67-0.94; p = 0.01), and teaching metropolitan hospital (OR 0.72, 95%CI:0.61-0.94; p = 0.01). Conclusion The unplanned 30-day readmission rates are higher in ARDS patients in the US. Several modifiable factors such as insurance, socioeconomic status, and hospital type are associated with 30-day readmission among ARDS patients.
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Affiliation(s)
- Harshil Shah
- Internal Medicine, Independent Researcher, Sayre, USA
| | - Uvesh Mansuri
- Medicine, MedStar Union Memorial Hospital, Baltimore, USA
| | - Sukrut Pagad
- Internal Medicine, Larkin Community Hospital, Hialeah, USA
| | - Reshmi Adupa
- Internal Medicine, Garden City Hospital, Garden City, USA
| | - Jagmeet Singh
- Nephrology, Geisinger Commonwealth School of Medicine, Scranton, USA
| | - Khin Tun
- Pediatrics, Independent Researcher, Yangon, MMR
| | - Chail Shah
- Internal Medicine, Brooklyn Cancer Care, Brooklyn, USA.,Internal Medicine, Mahatma Gandhi Medical College and Research Institute, Navi Mumbai, IND
| | | | - Priyal J Shah
- Internal Medicine, The Medical Center, Navicent Health, Macon, USA
| | - Mir Z Ali Khan
- Internal Medicine, Mercy Catholic Medical Center, Darby, USA
| | - Gurjot S Grewal
- Medicine, Christian Medical College & Hospital, Ludhiana, IND
| | - Ruchir Goswami
- Epidemiology and Public Health, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Shantanu Solanki
- Hospital-Based Medicine, Geisinger Commonwealth School of Medicine, Scranton, USA
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Abstract
PURPOSE OF REVIEW This review summarizes the results from long-term intensive care outcome research over the past 50 years. Key findings from early studies are reflected in citations of contemporary research. RECENT FINDINGS The postintensive care syndrome (PICS) is a multifaceted entity of residual disability and complications burdening survivors of critical illness. Some interventions applied early in the history of outcomes research have now been confirmed as effective in counteracting specific PICS components. SUMMARY Interest in patient-centred outcomes has been present since the beginning of modern intensive care. Findings from early long-term studies remain valid even in the face of contemporary large registries that facilitate follow-up of larger cohorts. A further understanding of the mechanisms leading to experienced physical and psychological impairment of PICS will be essential to the design of future intervention trials.
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23
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Jubran A, Grant BJB, Duffner LA, Collins EG, Lanuza DM, Hoffman LA, Tobin MJ. Long-Term Outcome after Prolonged Mechanical Ventilation. A Long-Term Acute-Care Hospital Study. Am J Respir Crit Care Med 2020; 199:1508-1516. [PMID: 30624956 DOI: 10.1164/rccm.201806-1131oc] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Rationale: Patients managed at a long-term acute-care hospital (LTACH) for weaning from prolonged mechanical ventilation are at risk for profound muscle weakness and disability. Objectives: To investigate effects of prolonged ventilation on survival, muscle function, and its impact on quality of life at 6 and 12 months after LTACH discharge. Methods: This was a prospective, longitudinal study conducted in 315 patients being weaned from prolonged ventilation at an LTACH. Measurements and Main Results: At discharge, 53.7% of patients were detached from the ventilator and 1-year survival was 66.9%. On enrollment, maximum inspiratory pressure (Pimax) was 41.3 (95% confidence interval, 39.4-43.2) cm H2O (53.1% predicted), whereas handgrip strength was 16.4 (95% confidence interval, 14.4-18.7) kPa (21.5% predicted). At discharge, Pimax did not change, whereas handgrip strength increased by 34.8% (P < 0.001). Between discharge and 6 months, handgrip strength increased 6.2 times more than did Pimax. Between discharge and 6 months, Katz activities-of-daily-living summary score improved by 64.4%; improvement in Katz summary score was related to improvement in handgrip strength (r = -0.51; P < 0.001). By 12 months, physical summary score and mental summary score of 36-item Short-Form Survey returned to preillness values. When asked, 84.7% of survivors indicated willingness to undergo mechanical ventilation again. Conclusions: Among patients receiving prolonged mechanical ventilation at an LTACH, 53.7% were detached from the ventilator at discharge and 1-year survival was 66.9%. Respiratory strength was well maintained, whereas peripheral strength was severely impaired throughout hospitalization. Six months after discharge, improvement in muscle function enabled patients to perform daily activities, and 84.7% indicated willingness to undergo mechanical ventilation again.
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Affiliation(s)
- Amal Jubran
- 1 Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,2 Loyola University of Chicago Stritch School of Medicine, Maywood, Illinois.,3 RML Specialty Hospital, Hinsdale, Illinois
| | | | - Lisa A Duffner
- 1 Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,2 Loyola University of Chicago Stritch School of Medicine, Maywood, Illinois.,3 RML Specialty Hospital, Hinsdale, Illinois
| | - Eileen G Collins
- 1 Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,2 Loyola University of Chicago Stritch School of Medicine, Maywood, Illinois.,3 RML Specialty Hospital, Hinsdale, Illinois.,5 University of Illinois at Chicago, Chicago, Illinois
| | | | | | - Martin J Tobin
- 1 Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois.,2 Loyola University of Chicago Stritch School of Medicine, Maywood, Illinois.,3 RML Specialty Hospital, Hinsdale, Illinois
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24
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Viswan A, Singh C, Kayastha AM, Azim A, Sinha N. An NMR based panorama of the heterogeneous biology of acute respiratory distress syndrome (ARDS) from the standpoint of metabolic biomarkers. NMR IN BIOMEDICINE 2020; 33:e4192. [PMID: 31733128 DOI: 10.1002/nbm.4192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/16/2019] [Accepted: 09/05/2019] [Indexed: 06/10/2023]
Abstract
Acute respiratory distress syndrome (ARDS), manifested by intricate etiology and pathophysiology, demands careful clinical surveillance due to its high mortality and imminent life support measures. NMR based metabolomics provides an approach for ARDS which culminates from a wide spectrum of illness thereby confounding early manifestation and prognosis predictors. 1 H NMR with its manifold applications in critical disease settings can unravel the biomarker of ARDS thus holding potent implications by providing surrogate endpoints of clinical utility. NMR metabolomics which is the current apogee platform of omics trilogy is contributing towards the possible panacea of ARDS by subsequent validation of biomarker credential on larger datasets. In the present review, the physiological derangements that jeopardize the whole metabolic functioning in ARDS are exploited and the biomarkers involved in progression are addressed and substantiated. The following sections of the review also outline the clinical spectrum of ARDS from the standpoint of NMR based metabolomics which is an emerging element of systems biology. ARDS is the main premise of intensivists textbook, which has been thoroughly reviewed along with its incidence, progressive stages of severity, new proposed diagnostic definition, and the preventive measures and the current pitfalls of clinical management. The advent of new therapies, the need for biomarkers, the methodology and the contemporary promising approaches needed to improve survival and address heterogeneity have also been evaluated. The review has been stepwise illustrated with potent biometrics employed to selectively pool out differential metabolites as diagnostic markers and outcome predictors. The following sections have been drafted with an objective to better understand ARDS mechanisms with predictive and precise biomarkers detected so far on the basis of underlying physiological parameters having close proximity to diseased phenotype. The aim of this review is to stimulate interest in conducting more studies to help resolve the complex heterogeneity of ARDS with biomarkers of clinical utility and relevance.
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Affiliation(s)
- Akhila Viswan
- Centre of Biomedical Research, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS) - Campus, Lucknow, Uttar Pradesh, India
- Faculty of Engineering and Technology, Dr. A. P. J Abdul Kalam Technical University, Lucknow, India
| | - Chandan Singh
- Centre of Biomedical Research, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS) - Campus, Lucknow, Uttar Pradesh, India
- School of Biotechnology, Institute of Science, Banaras Hindu University, Varanasi, India
| | - Arvind M Kayastha
- School of Biotechnology, Institute of Science, Banaras Hindu University, Varanasi, India
| | - Afzal Azim
- Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Neeraj Sinha
- Centre of Biomedical Research, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS) - Campus, Lucknow, Uttar Pradesh, India
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Aftermath of Respiratory Failure: Recovery or Decline? Crit Care Med 2019. [PMID: 29538117 DOI: 10.1097/ccm.0000000000002974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Acute respiratory distress syndrome continues to have high morbidity and mortality despite more than 50 years of research. The Berlin definition in 2012 established risk stratification based on degree of hypoxemia and the use of positive end-expiratory pressure. The use of prone positioning as a treatment modality has been studied for more than 40 years, with recent studies showing an improvement in oxygenation and decreased mortality. The studies also provide evidence to support the methodology and length of treatment time. Recent guidelines include several ventilator strategies for acute respiratory distress syndrome, including prone positioning. Protocols and procedures discussed in this article ensure successful prone repositioning and prevention of complications related to the procedure itself.
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Affiliation(s)
- Dannette A Mitchell
- Dannette A. Mitchell is Critical Care Clinical Nurse Specialist, Christiana Care Health Service, Wilmington Hospital, 501 W 14th Street, Intensive Care and Transitional Care Unit - 6S45, Wilmington, DE 19801 . Maureen A. Seckel is Lead Critical Care Clinical Nurse Specialist and Sepsis Leader, Christiana Care Health Service, Christiana Hospital, Newark, Delaware
| | - Maureen A Seckel
- Dannette A. Mitchell is Critical Care Clinical Nurse Specialist, Christiana Care Health Service, Wilmington Hospital, 501 W 14th Street, Intensive Care and Transitional Care Unit - 6S45, Wilmington, DE 19801 . Maureen A. Seckel is Lead Critical Care Clinical Nurse Specialist and Sepsis Leader, Christiana Care Health Service, Christiana Hospital, Newark, Delaware
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Happ MB, Mion LC, Duffy S. The challenge of multiple complex chronic conditions. Geriatr Nurs 2018; 39:244-246. [PMID: 29685208 DOI: 10.1016/j.gerinurse.2018.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Mary Beth Happ
- The Ohio State University College of Nursing, Center of Excellence in Critical and Complex Care, Columbus, OH 43210, USA.
| | - Lorraine C Mion
- The Ohio State University College of Nursing, Center of Excellence in Critical and Complex Care, Columbus, OH 43210, USA
| | - Sonia Duffy
- The Ohio State University College of Nursing, Center of Excellence in Critical and Complex Care, Columbus, OH 43210, USA
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The Outcome of Patients With Acute Respiratory Distress Syndrome Admitted to an ICU*. Crit Care Med 2018; 46:1013-1014. [DOI: 10.1097/ccm.0000000000003094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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