An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12-month follow-up study

Family-centered interventions and patient outcomes in the adult intensive care unit: A systematic review of randomized controlled trials

OBJECTIVE

There is a need to understand how family engagement in the intensive care unit (ICU) impacts patient outcomes. We reviewed the literature for randomized family-centered interventions with patient-related outcomes in the adult ICU.

DATA SOURCES

The MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library databases were searched from inception until July 3, 2023.

STUDY SELECTION

Articles involving randomized controlled trials (RCTs) in the adult critical care setting evaluating family-centered interventions and reporting patient-related outcomes.

DATA EXTRACTION

Author, publication year, setting, number of participants, intervention category, intervention, and patient-related outcomes (patient-reported, physiological, clinical) were extracted.

DATA SYNTHESIS

There were 28 RCTs (12,174 participants) included. The most common intervention types were receiving care and meeting needs (N = 10) and family presence (N = 7). 16 RCTs (57%) reported ≥1 positive outcome from the intervention; no studies reported worse outcomes. Studies reported improvements in patient-reported outcomes such as anxiety, satisfaction, post-traumatic stress symptoms, depression, and health-related quality of life. RCTs reported improvements in physiological indices, adverse events, mechanical ventilation duration, analgesia use, ICU length of stay, delirium, and time to withdrawal of life-sustaining treatments.

CONCLUSIONS

Nearly two-thirds of RCTs evaluating family-centered interventions in the adult ICU reported positive patient-related outcomes.

KEYPOINTS

Question: Do family-centered interventions improve patient outcomes in the adult intensive care unit (ICU)?

FINDINGS

The systematic review found that nearly two-thirds of randomized clinical trials of family-centered interventions in the adult ICU improved patient outcomes. Studies found improvements in patient mental health, care satisfaction, physiological indices, and clinical outcomes. There were no studies reporting worse patient outcomes. Meaning: Many family-centered interventions can improve patient outcomes.

Long-term outcomes and associated factors among intensive care unit survivors in a low-income country: a multicenter prospective cohort study

OBJECTIVE

Post-ICU survivors face higher mortality and often require costly rehabilitation or palliative care, such as occupational therapy, physiotherapy and hospice. However, there is a lack of data quantifying the demand for these services, particularly in developing countries like Uganda. Therefore, this prospective cohort study aimed to investigate the 90-day mortality rate, functional status, and mortality risk factors among 121 ICU patients discharged from three tertiary hospital ICUs in Uganda by tracking their vital and physical functional status for three months with follow-ups on days 30, 60, and 90, and identifying risk factors through Cox regression.

RESULTS

The study revealed that 18 out of 121 ICU patients (14.88%, 95% CI: 9.52-22.51%) died within 90 days post-discharge, while 36.36% achieved normal physical functional status. Factors associated with higher 90-day mortality included raised intracranial pressure (HR 1.92, 95% CI: 1.76-2.79, p = 0.04), acute kidney injury (HR 4.13, 95% CI: 2.16-7.89, p < 0.01), and renal replacement therapy (HR 3.34, 95% CI: 2.21-5.06, p < 0.01). The high mortality rate and the fact that nearly two-thirds of patients did not attain normal functional status 90 days post discharge underscores the need for enhanced post-ICU rehabilitation services.

Impact of Muscle Changes Assessed by Ultrasonography on Muscle Strength and Functioning after ICU Discharge: A Systematic Review with Meta-Analysis

BACKGROUND

Ultrasonography has been used to identify structural, quantitative, and qualitative muscle changes. These changes have been assessed in different muscles during ICU stays; however, it is unclear if it can predict functioning after ICU discharge.

OBJECTIVE

To analyze the relationship between muscle changes assessed by ultrasonography and the strength and functioning of ICU survivors.

METHODS

A systematic review with a meta-analysis was performed according to the MOOSE guidelines and registered in PROSPERO. Searches of the following databases were performed by two of the authors: PubMed, Cinahl, Embase, Scopus, LILACS, Web of Science, and Science Direct. Qualitative analysis was performed using NOS and AHRQ scales. Meta-analysis was performed using the "R", "metafor" package. Heterogeneity was assessed by I2 and Cochran's Q test. Meta-regression analyses were performed to verify the moderators, and funnel plots and Egger's regression intercept test were used to analyze the publication bias.

RESULTS

Sixteen articles were included in the qualitative assessment, and nine were used in the quantitative assessment. There is evidence of correlations between MT and muscle strength (r = 0.20 [0.11; 0.27]; p < 0.0001), and MT (r = 0.35 [0.19; 0.49]; p < 0.0001), CSA (r = 0.30 [0.10; 0.47]; p = 0.0038), EI (r = -0.29 [-0.53; -0.01]; p = 0.043) and mobility. In the subgroup analyses, some evidence of a correlation between specific muscles and strength and mobility were found.

CONCLUSIONS

There is evidence for the correlation between muscle characteristics assessed by US and functioning outcomes.

Post-intensive care syndrome screening: a French multicentre survey

BACKGROUND

Post-intensive care syndrome (PICS), defined as physical, cognitive, and mental-health symptoms persisting long after intensive-care-unit (ICU) discharge, is increasingly recognised as a healthcare priority. Data on screening for PICS are sparse. Our objective here was to describe post-ICU screening in France, with special attention to visit availability and evaluations done during visits.

METHODS

We conducted an online multicentre survey by emailing an anonymous 43-item questionnaire to French ICUs. For each ICU, a single survey was sent to either the head or the intensivist in charge of follow-up visits.

RESULTS

Of 252 ICUs invited to participate, 161 (63.9%) returned the completed survey. Among them, 46 (28.6%) offered follow-up visits. Usually, a single visit led by an intensivist was scheduled 3 to 6 months after ICU discharge. Approximately 50 patients/year/ICU, that is, about 5% of admitted patients, attended post-ICU visits. The main criteria used to select patients for follow-up were ICU stay and/or invasive mechanical ventilation duration longer than 48 h, cardiac arrest, septic shock, and acute respiratory distress syndrome. Among ICUs offering visits, 80% used validated instruments to screen for PICS. Of the 115 ICUs not offering follow-up, 50 (43.5%) indicated an intention to start follow-up within the next year. The main barriers to offering follow-up were lack of available staff and equipment or not viewing PICS screening as a priority. Half the ICUs offering visits worked with an established network of post-ICU care professionals, and another 17% were setting up such a network. Obstacles to network creation were lack of interest among healthcare professionals and lack of specific training in PICS.

CONCLUSION

Only a small minority of ICU survivors received follow-up designed to detect PICS. Less than a third of ICUs offered follow-up visits but nearly another third planned to set up such visits within the next year. Recommendations issued by French health authorities in 2023 can be expected to improve the availability and standardisation of post-ICU follow-up.

Factors Associated With New Analgesic Requirements Following Critical Illness

BACKGROUND

Chronic opioid use represents a significant burden to global healthcare with adverse long-term outcomes. Elevated patient reported pain levels and analgesic prescriptions have been reported following discharge from critical care. We describe analgesic requirements following discharge from hospital and identify if a critical care admission is a significant factor for stronger analgesic prescriptions.

METHODS

This retrospective observational cohort study identified patients in the UK Biobank with a registered admission to any UK hospital between January 1, 2010 and December 31, 2015 and information on prescriptions drawn both prior to and following hospital discharge. Two matched cohorts were created from the dataset: critical care patients and hospital patients admitted without a critical care encounter. Outcomes were analgesic requirements following hospital discharge and factors associated with increased analgesic prescriptions. Multivariable logistic regression was used to identify factors associated with prescriptions from higher steps on the World Health Organization (WHO) analgesic ladder.

RESULTS

In total, 660 formed the total study population. Strong opioid prescriptions following discharge were significantly higher in the critical care cohort (P value <.001). Critical care admission (OR = 1.45) and increasing Townsend deprivation (OR = 1.04) index were significantly associated with increasing strength of analgesic prescriptions following discharge.

CONCLUSIONS

Critical care patients require stronger analgesic prescriptions in the 12 months following hospital discharge. Patients from areas of high socioeconomic deprivation may also be associated with increased analgesic requirements. Multidisciplinary support is required for patients who may be at risk of chronic opioid use and could be delivered within critical care recovery programs.

Post intensive care syndrome: A review of clinical symptoms, evaluation, intervention

Post intensive care syndrome (PICS) is a typical complication of critically ill patients during or after their stay in intensive care unit (ICU), characterized by a high incidence and impairment rate. It significantly impacts the quality of life of patients and their families, as well as consumes a substantial amount of medical resources. Therefore, early intervention and assessment of PICS is crucial. This paper aims to provide clinical professionals with a reference base by focusing on the clinical symptoms, diagnostic assessment, and preventative measures of PICS.

Evaluating Mental Health Outcomes in COVID-19 ICU Survivors: A Scoping Review of Measurement Tools

Objective: The objective of this scoping review was to map the range of measurement tools used to study the prevalence of common mental health conditions in COVID-19 ICU survivors. Introduction: Increased rates of admission to and survivorship from intensive care units (ICUs) have been observed in recent years, particularly during the global pandemic. ICU patients are at a higher risk of developing depressive, anxiety, and PTSD symptoms. Due to the high burden of disease, an accurate understanding of long-term mental health challenges for this population is key. Unfortunately, there is significant variability in reported prevalence rates. Heterogeneity in measurement tools potentially contribute to this. Inclusion criteria: Studies were eligible if they (a) reported mental health outcomes of adult patients diagnosed with COVID-19 and admitted to an ICU, (b) used standardised mental health outcome measures, and (3) were peer-reviewed. Methods: Searches were conducted in PubMed, PsycInfo, and Scopus. The initial search retrieved 1234 publications. After de-duplication and title and abstract screening, 72 full-text articles were examined for eligibility and 44 articles were excluded, leaving 28 eligible studies. Reference lists of the eligible studies were screened, and four other studies were added. 32 studies were ultimately included in this review. Results: Significant heterogeneity of measurement tools and clinical thresholds were observed. Only 6.25% of the studies compared changes in mental health outcomes to baseline measurements. Between five and nine unique measurement tools were used to study depression, anxiety, and PTSD, respectively. Studies were also observed to use up to 19 different thresholds to establish the prevalence of PTSD. Conclusions: The heterogeneity of measurement tools and thresholds continues to confound prevalence rate estimations of mental health complications post-ICU admission. Future research will benefit from consistency in the use of recommended outcome measures and the use of psychometrically comparable cut-off points between key measures.

The impact of quality-adjusted life years on evaluating COVID-19 mitigation strategies: lessons from age-specific vaccination roll-out and variants of concern in Belgium (2020-2022)

BACKGROUND

When formulating and evaluating COVID-19 vaccination strategies, an emphasis has been placed on preventing severe disease that overburdens healthcare systems and leads to mortality. However, more conventional outcomes such as quality-adjusted life years (QALYs) and inequality indicators are warranted as additional information for policymakers.

METHODS

We adopted a mathematical transmission model to describe the infectious disease dynamics of SARS-COV-2, including disease mortality and morbidity, and to evaluate (non)pharmaceutical interventions. Therefore, we considered temporal immunity levels, together with the distinct transmissibility of variants of concern (VOCs) and their corresponding vaccine effectiveness. We included both general and age-specific characteristics related to SARS-CoV-2 vaccination. Our scenario study is informed by data from Belgium, focusing on the period from August 2021 until February 2022, when vaccination for children aged 5-11 years was initially not yet licensed and first booster doses were administered to adults. More specifically, we investigated the potential impact of an earlier vaccination programme for children and increased or reduced historical adult booster dose uptake.

RESULTS

Through simulations, we demonstrate that increasing vaccine uptake in children aged 5-11 years in August-September 2021 could have led to reduced disease incidence and ICU occupancy, which was an essential indicator for implementing non-pharmaceutical interventions and maintaining healthcare system functionality. However, an enhanced booster dose regimen for adults from November 2021 onward could have resulted in more substantial cumulative QALY gains, particularly through the prevention of elevated levels of infection and disease incidence associated with the emergence of Omicron VOC. In both scenarios, the need for non-pharmaceutical interventions could have decreased, potentially boosting economic activity and mental well-being.

CONCLUSIONS

When calculating the impact of measures to mitigate disease spread in terms of life years lost due to COVID-19 mortality, we highlight the impact of COVID-19 on the health-related quality of life of survivors. Our study underscores that disease-related morbidity could constitute a significant part of the overall health burden. Our quantitative findings depend on the specific setup of the interventions under review, which is open to debate or should be contextualised within future situations.

An environmental scan of online resources for informal family caregivers of ICU survivors

PURPOSE

To collate a comprehensive repository of online resources for family caregivers of intensive care survivors to inform a recovery website and digital peer support programme.

MATERIALS AND METHODS

To identify resources, we conducted an environmental scan using processes recommended by the Canadian Agency for Drugs and Technologies in Health and guided by clinical experts, former patients, and family members. We searched internet sources, professional society websites, social media, and contacted our professional networks.

RESULTS

Through expert consultation we identified 16 information categories and found 301 online resources. Five categories with the most resources were: how to look after yourself/recognise anxiety or post-traumatic stress/getting mental health support (n = 63); information specific to conditions necessitating ICU admission (n = 49); multiple category resources (n = 46); symptoms of post-intensive care syndrome (n = 44); stories of lived experience (n = 23). Five categories with the least resources were physical, emotional and cognitive symptoms of post-intensive care syndrome-family (n = 1); interacting with primary care (n = 2); medical deterioration (how to recognise/what to do) (n = 2); driving and accessing the community (n = 3); end-of-life and bereavement (n = 5). Of these resources, we included 45 on our recovery website.

CONCLUSION

This environmental scan identifies multiple resources addressing informational needs of family caregivers and highlights areas for resource development.

The impact of critical illness on patients' physical function and recovery: An explanatory mixed-methods analysis

OBJECTIVES

To determine how the perception of physical function 6-months following critical illness compares to objectively measured function, and to identify key concerns for patients during recovery from critical illness.

RESEARCH METHODOLOGY AND DESIGN

A nested convergent parallel mixed methods study assessed physical function during a home visit 6-months following critical illness, with semi-structured interviews conducted at the same time.

SETTING

Participants were recruited from two hospitals at one healthcare network in Melbourne, Australia from September 2017 to October 2018 with follow-up data completed in April 2019.

MAIN OUTCOME MEASURES

Physical function was assessed through four objective outcomes: the functional independence measure, six-minute walk test, functional reach test, and grip strength. Semi structured interviews focused on participants function, memories of the intensive care and hospital stay, assistance required on discharge, ongoing limitations, and the recovery process.

FINDINGS

Although many participants (12/20, 60%) stated they had recovered from their critical illness, 14 (70%) had function below expected population norms. Decreased function on returning home was commonly reported, although eleven participants were described as independent and safe for discharge from hospital-based staff. The importance of family and social networks to facilitate discharge was highlighted, however participants often described wanting more support and issues accessing services. The effect of critical illness on the financial well-being of the family network was confirmed, with difficulties accessing financial support identified.

CONCLUSION

Survivors of critical illness perceived a better functional state than measured, but many report new limitations 6-months after critical illness. Family and friends play a crucial role in facilitating transition home and providing financial support.

IMPLICATIONS FOR CLINICAL PRACTICE

Implementation of specific discharge liaison personnel to provide education, support and assist the transition from hospital-based care to home, particularly in those without stable social supports, may improve the recovery process for survivors of critical illness.

Recovery following discharge from intensive care: What do patients think is helpful and what services are missing?

BACKGROUND

Recovery following critical illness is complex due to the many challenges patients face which influence their long-term outcomes. We explored patients' views about facilitators of recovery after critical illness which could be used to inform the components and timing of specific rehabilitation interventions.

AIMS

To explore the views of patients after discharge from an intensive care unit (ICU) about their recovery and factors that facilitated recovery, and to determine additional services that patients felt were missing during their recovery.

METHODS

Qualitative study involving individual face-to-face semi-structured interviews at six months (n = 11) and twelve months (n = 10). Written, informed consent was obtained. [Ethics approval 17/NI/0115]. Interviews were audiotaped, transcribed and analysed using template analysis.

FINDINGS

Template analysis revealed four core themes: (1) Physical activity and function; (2) Recovery of cognitive and emotional function; (3) Facilitators to recovery; and (4) Gaps in healthcare services.

CONCLUSION

Patient reported facilitators to recovery include support and guidance from others and self-motivation and goal setting, equipment for mobility and use of technology. Barriers include a lack of follow up services, exercise rehabilitation, peer support and personal feedback. Patients perceived that access to specific healthcare services was fragmented and where services were unavailable this contributed to slower or poorer quality of recovery. ICU patient recover could be facilitated by a comprehensive rehabilitation intervention that includes patient-directed strategies and health care services.

Persistent inflammation, immunosuppression, and catabolism syndrome (PICS): a review of definitions, potential therapies, and research priorities

Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PICS) is a clinical endotype of chronic critical illness. PICS consists of a self-perpetuating cycle of ongoing organ dysfunction, inflammation, and catabolism resulting in sarcopenia, immunosuppression leading to recurrent infections, metabolic derangements, and changes in bone marrow function. There is heterogeneity regarding the definition of PICS. Currently, there are no licensed treatments specifically for PICS. However, findings can be extrapolated from studies in other conditions with similar features to repurpose drugs, and in animal models. Drugs that can restore immune homeostasis by stimulating lymphocyte production could have potential efficacy. Another treatment could be modifying myeloid-derived suppressor cell (MDSC) activation after day 14 when they are immunosuppressive. Drugs such as interleukin (IL)-1 and IL-6 receptor antagonists might reduce persistent inflammation, although they need to be given at specific time points to avoid adverse effects. Antioxidants could treat the oxidative stress caused by mitochondrial dysfunction in PICS. Possible anti-catabolic agents include testosterone, oxandrolone, IGF-1 (insulin-like growth factor-1), bortezomib, and MURF1 (muscle RING-finger protein-1) inhibitors. Nutritional support strategies that could slow PICS progression include ketogenic feeding and probiotics. The field would benefit from a consensus definition of PICS using biologically based cut-off values. Future research should focus on expanding knowledge on underlying pathophysiological mechanisms of PICS to identify and validate other potential endotypes of chronic critical illness and subsequent treatable traits. There is unlikely to be a universal treatment for PICS, and a multimodal, timely, and personalised therapeutic strategy will be needed to improve outcomes for this growing cohort of patients.

Reduced health-related quality of life, fatigue, anxiety and depression affect COVID-19 patients in the long-term after chronic critical illness

The term chronic critical illness describes patients suffering from persistent organ dysfunction and prolonged mechanical ventilation. In severe cases, COVID-19 led to chronic critical illness. As this population was hardly investigated, we evaluated the health-related quality of life, physical, and mental health of chronically critically ill COVID-19 patients. In this prospective cohort study, measurements were conducted on admission to and at discharge from inpatient neurorehabilitation and 3, 6, and 12 months after discharge. We included 97 patients (61 ± 12 years, 31% women) with chronic critical illness; all patients required mechanical ventilation. The median duration of ICU-treatment was 52 (interquartile range 36-71) days, the median duration of mechanical ventilation was 39 (22-55) days. Prevalences of fatigue, anxiety, and depression increased over time, especially between discharge and 3 months post-discharge and remained high until 12 months post-discharge. Accordingly, health-related quality of life was limited without noteworthy improvement (EQ-5D-5L: 0.63 ± 0.33). Overall, the burden of symptoms was high, even one year after discharge (fatigue 55%, anxiety 42%, depression 40%, problems with usual activities 77%, pain/discomfort 84%). Therefore, patients with chronic critical illness should receive attention regarding treatment after discharge with a special focus on mental well-being.Trial registration: German Clinical Trials Register, DRKS00025606. Registered 21 June 2021-Retrospectively registered, https://drks.de/search/de/trial/DRKS00025606 .

Outcome of severe COVID-19: spotlight on fatigue, fatigability, multidomain complaints and pattern of cognitive deficits in a case series without prior brain dysfunction and without COVID-19-related stroke and/or cardiac arrest

BACKGROUND

Population-wide surveys and large-scale investigations highlighted the presence of cognitive deficits in the acute and postacute stages of severe COVID-19; a few studies documented their occurrence in cases without prior or COVID-19-related brain damage. The evolution of cognitive deficits in the latter population and their relationship to the post-COVID-19 fatigue syndrome are poorly understood.

CASE PRESENTATION

We report the outcome at 12 months after severe COVID-19 involving an intensive care unit stay and mechanical ventilation in six (five Caucasian and one Asian) patients (age range: 53-71 years, mean age 61.7 ± 6.5 years) without history of prior brain dysfunction and without stroke and/or cardiac arrest during or after COVID-19. All patients reported pervading mental and physical fatigue as well as numerous multidomain complaints, which impacted everyday life. Individual patients described mental fatigability, apathy, and/or anxiety. Standardized neuropsychological tests revealed isolated symptoms of cognitive dysfunction or performance at the lower limit of the norm in the attentional, executive, and/or working memory domains in four of the six patients. Somatic scales documented dyspnoea, muscle weakness, olfactory disorder, and/or minor sleep problems in some, but not all, patients.

CONCLUSION

Fatigue, fatigability, multidomain complaints, cognitive difficulties, or dysfunction, as well as isolated neurobehavioral and/or psychiatric and/or somatic symptoms, tend to occur in the aftermath of severe COVID-19 and persist at 12 months, even in the absence of prior and/or COVID-19-related brain damage. This clinical situation, which impacts everyday life, calls for a detailed investigation of patients' complaints, its neural underpinning, and an elaboration of specific rehabilitation programs.

Up against the wall - emergency double myocardial rupture repair

BACKGROUND

Left ventricular free wall rupture (LVFWR) and interventricular septal rupture (VSR) are potentially catastrophic mechanical complications after acute myocardial infarction (AMI). When they occur together, "double myocardial rupture" (DMR), survival is unlikely. DMR is seen in only 0.3% of all AMIs. With or without surgical intervention, the odds are against the patient.

CASE PRESENTATION

A 57-year-old male self-referred to the emergency department of a remote hospital 5 days after first experiencing chest pain. Investigations in ED confirmed an inferior ST-segment elevation myocardial infarction (STEMI) complicated by DMR. Coronary angiography revealed a mid-course total occlusion of the right coronary artery (RCA). He was rapidly transferred to our regional cardiac surgical unit, arriving straight into the operating theatre, in cardiogenic shock. He was briefly conscious, before arresting prior to intubation and being massaged onto bypass. Not only did he survive the all-night operation, requiring a mitral valve replacement in the process, but he survived multiple postoperative complications to be eventually transferred on postoperative day 66, neurologically intact, to a peripheral unit to complete his rehabilitation. He was subsequently discharged home 88 days after the operation and was able to ambulate with a walking frame into his first postoperative follow-up clinic appointment.

CONCLUSIONS

Our patient, against all odds, has survived DMR and multiple postoperative complications. We present the details of his case and the literature surrounding the condition. The patient's mental fortitude and his supportive family played a significant role, along with excellent multidisciplinary team work, in assuring his survival.

Societal costs of sepsis in the Netherlands

BACKGROUND

Sepsis is a life-threatening syndrome characterized by acute loss of organ function due to infection. Sepsis survivors are at risk for long-term comorbidities, have a reduced Quality of Life (QoL), and are prone to increased long-term mortality. The societal impact of sepsis includes its disease burden and indirect economic costs. However, these societal costs of sepsis are not fully understood. This study assessed sepsis's disease-related and indirect economic costs in the Netherlands.

METHODS

Sepsis prevalence, incidence, sepsis-related mortality, hospitalizations, life expectancy, QoL population norms, QoL reduction after sepsis, and healthcare use post-sepsis were obtained from previous literature and Statistics Netherlands. We used these data to estimate annual Quality-adjusted Life Years (QALYs), productivity loss, and increase in healthcare use post-sepsis. A sensitivity analysis was performed to analyze the burden and indirect economic costs of sepsis under alternative assumptions, resulting in a baseline, low, and high estimated burden. The results are presented as a baseline (low-high burden) estimate.

RESULTS

The annual disease burden of sepsis is approximately 57,304 (24,398-96,244; low-high burden) QALYs. Of this, mortality accounts for 26,898 (23,166-31,577) QALYs, QoL decrease post-sepsis accounts for 30,406 (1232-64,667) QALYs. The indirect economic burden, attributed to lost productivity and increased healthcare expenditure, is estimated at €416.1 (147.1-610.7) million utilizing the friction cost approach and €3.1 (0.4-5.7) billion using the human capital method. Cumulatively, the combined disease and indirect economic burdens range from €3.8 billion (friction method) to €6.5 billion (human capital method) annually within the Netherlands.

CONCLUSIONS

Sepsis and its complications pose a substantial disease and indirect economic burden to the Netherlands, with an indirect economic burden due to production loss that is potentially larger than the burden due to coronary heart disease or stroke. Our results emphasize the need for future studies to prevent sepsis, saving downstream costs and decreasing the economic burden.

Prognostic factors for deterioration of quality of life one year after admission to ICU for severe SARS-COV2 infection

PURPOSE

Patients with COVID-19 present long-term symptoms collectively known as "post-COVID syndrome". Long-term manifestations are more frequent in patients requiring admission to Intensive Care Units (ICU), but the risk factors for their development are still unknown. This study explores the quality of life of patients with severe COVID-19 one year after their discharge from ICU.

METHODS

Prospective observational study including 106 patients admitted to the ICU of a tertiary care hospital between March and August 2020. We analysed quality of life using the EuroQol-5D index (EQ-5D). We evaluated as possible risk factors associated with a worse value of the EQ-5D index the medical record, the clinical situation at hospital admission, the clinical situation at ICU admission and evolution in the ICU. As a secondary objective, we explored the presence of other frequent symptoms.

RESULTS

Most patients (55.4%) reported that their quality of life worsened one year after admission. The mean perceived health status, on the EQ-VAS scale (0-100), was 70.4, with a median of 70 (RI 60-90). The median EQ-5D index was 0.91 (RI 0.76-1). The factors independently related to lower quality of life were female sex and duration of mechanical ventilation. Almost all (91%) of the patients had sequelae one year after discharge from the ICU. The most frequent manifestations were neuropsychiatric (71%).

CONCLUSIONS

Critically ill COVID-19 patients worsen their quality of life more than one year after discharge. Female sex and duration of mechanical ventilation predict a lower quality of life assessed by the EQ-5D index.

Modeling the potential public health and economic impact of different COVID-19 booster dose vaccination strategies with an adapted vaccine in the United Kingdom

BACKGROUND

Updating vaccines is essential for combatting emerging coronavirus disease 2019 (COVID-19) variants. This study assessed the public health and economic impact of a booster dose of an adapted vaccine in the United Kingdom (UK).

METHODS

A Markov-decision tree model estimated the outcomes of vaccination strategies targeting various age and risk groups in the UK. Age-specific data derived from published sources were used. The model estimated case numbers, deaths, hospitalizations, medical costs, and societal costs. Scenario analyses were conducted to explore uncertainty.

RESULTS

Vaccination targeting individuals aged ≥ 65 years and the high-risk population aged 12-64 years was estimated to avert 701,549 symptomatic cases, 5,599 deaths, 18,086 hospitalizations, 56,326 post-COVID condition cases, and 38,263 lost quality-adjusted life years (QALYs), translating into direct and societal cost savings of £112,174,054 and £542,758,682, respectively. The estimated economically justifiable price at willingness-to-pay thresholds of £20,000 and £30,000 per QALY was £43 and £61, respectively, from the payer perspective and £64 and £82, respectively, from the societal perspective. Expanding to additional age groups improved the public health impact.

CONCLUSIONS

Targeting individuals aged ≥ 65 years and those aged 12-64 years at high risk yields public health gains, but expansion to additional age groups provides additional gains.

Advances in post intensive care unit care: A narrative review

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.

Physical therapy in the intensive care unit: A cross-sectional study of three Asian countries

BACKGROUND

Physical therapy (PT) is beneficial for critically ill patients, but the extent of its application in the intensive care unit (ICU) differs between countries. Here, we compared the extent of PT intervention in the ICU in Japan, the Philippines, and Taiwan by evaluating the sociodemographic and ICU-related profiles of ICU physical therapists.

MATERIALS AND METHODS

In this cross-sectional study, a semistructured nationwide online survey was distributed to ICU physical therapists in the three countries.

RESULTS

We analyzed the responses of 164 physical therapists from Japan, Philippines, and Taiwan. Significant differences were observed between the countries in all sociodemographic variables and the following ICU-related profiles of physical therapists: ICU work experience, duration of the ICU posting, number of hours per day spent in the ICU, on-call ICU PT service engagement, source of ICU patient referral, therapist-patient ratio, and ICU-related PT training participation (p < 0.05). Medical, surgical, and neurologic ICUs were the most common ICU workplaces of the ICU physical therapists, but only surgical and neurologic ICUs exhibited significant differences between the countries (p < 0.05). Standard PT techniques in the ICU were passive and active-assisted range of motion, positioning, and breathing exercises but were implemented with significantly different frequencies between the countries (p < 0.05). The most common challenge faced in ICU PT service delivery by respondents from all three countries was lack of training prior to ICU duty, and lack of training was even bigger challenge in Japan than in other two countries after adjustment of age, highest educational attainment, and work experience.

CONCLUSION

The differences in the health-care system between Japan, the Philippines, and Taiwan were related to differences in the compliance with internationally recommended PT practice standards in the ICU, differences in the type of PT intervention prioritized, and the challenges encountered in ICU PT service delivery.

Cognitive Impairment, Physical Impairment, and Psychological Symptoms in Intensive Care Unit Survivors

BACKGROUND

Post-intensive care syndrome (PICS) affects 25% to 50% of adults who survive an intensive care unit (ICU) stay. Although the compounding of PICS impairments (cognitive, physical, and psychological) could intensify the syndrome, research on relationships among impairments is limited, particularly in patients with delirium.

OBJECTIVES

To examine associations among PICS impairments and examine delirium status and its relationship to PICS impairments at ICU discharge and 1 month later.

METHODS

A descriptive, correlational study of adults who survived an ICU stay. Participants completed measures for depression, anxiety, posttraumatic stress, physical function, functional status, and cognition at ICU discharge and 1 month later. Relationships among PICS impairments were examined with Spearman correlations; differences in impairments by delirium status were assessed with t tests.

RESULTS

Of 50 enrolled participants, 46 were screened for PICS impairment at ICU discharge and 35 were screened 1 month later. Cognitive impairment was the most common impairment at both time points. A positive correlation was found between cognition and functional status at ICU discharge (ρ = 0.50, P = .001) and 1 month later (ρ = 0.54, P = .001). Cognition and physical functioning were positively correlated 1 month after discharge (ρ = 0.46, P = .006). The group with delirium had significantly lower functional status scores than the group without delirium at ICU discharge (P = .04).

CONCLUSIONS

The findings suggest a moderate correlation between cognitive and physical impairments. This relationship should be explored further; ICU survivors with undiagnosed cognitive impairment may have delayed physical recovery and greater risk for injury.

Hospital admission is associated with disability and late musculoskeletal pain in individuals with long COVID

Background

The acute clinical repercussions of SARS-CoV-2 infection have been widely studied. However, the possible late repercussions of long COVID have not yet been well defined in the literature.

Objectives

To identify the presence of pain and musculoskeletal disability in patients with Long COVID and also to identify predictive factors for pain intensity in this population.

Methods

In this cross-sectional and retrospective observational study individuals with Long COVID symptoms were included. It was collected musculoskeletal disability measures, data from patient-related outcome measures and variables from a COVID-19 outpatient service database. Associations and sub-group analyses were performed considering the variables pain, disability and hospitalization. Linear regression was performed to identify predictive factors for pain intensity in Long COVID patients.

Results

We evaluated 195 patients and most of them (57%) presented musculoskeletal pain in one area of the body. Pain sub-group presented worse disability indices and worse clinical course during hospitalization. Hospitalized patients presented worse disability indices comparing to non-hospitalized. Significant correlations were found between pain and days of non-invasive oxygen support (r = 0.21; p = 0.003); days in intensive care unit (r = 0.22; p = 0.002) and days in invasive mechanical ventilation (r = 0.35; p = 0.001). Hospitalized individuals showed a higher chance of presenting late musculoskeletal pain (OR = 1.42: 95%CI 1.09-2.04). Days in intensive care unit (β = 0,234: P = 0,001) and days in invasive mechanical ventilation (β = 0.764: P = 0.001) were predictors of pain intensity [F(2,192) = 18.559; R2 = 0.231; p = 0.001].

Conclusion

Individuals with Long COVID presented musculoskeletal pain and disability. Hospitalized patients showed a greater chance of having musculoskeletal pain. Days in intensive care unit and days in invasive mechanical ventilation were predictors of late musculoskeletal pain intensity.

Dialysis resource allocation in critical care: the impact of the COVID-19 pandemic and the promise of big data analytics

The COVID-19 pandemic resulted in an unprecedented burden on intensive care units (ICUs). With increased demands and limited supply, critical care resources, including dialysis machines, became scarce, leading to the undertaking of value-based cost-effectiveness analyses and the rationing of resources to deliver patient care of the highest quality. A high proportion of COVID-19 patients admitted to the ICU required dialysis, resulting in a major burden on resources such as dialysis machines, nursing staff, technicians, and consumables such as dialysis filters and solutions and anticoagulation medications. Artificial intelligence (AI)-based big data analytics are now being utilized in multiple data-driven healthcare services, including the optimization of healthcare system utilization. Numerous factors can impact dialysis resource allocation to critically ill patients, especially during public health emergencies, but currently, resource allocation is determined using a small number of traditional factors. Smart analytics that take into account all the relevant healthcare information in the hospital system and patient outcomes can lead to improved resource allocation, cost-effectiveness, and quality of care. In this review, we discuss dialysis resource utilization in critical care, the impact of the COVID-19 pandemic, and how AI can improve resource utilization in future public health emergencies. Research in this area should be an important priority.

Patient-reported impact of emergency laparotomy on employment and health status 1 year after surgery

BACKGROUND

Whilst there has been significant improvement in mortality outcomes after emergency laparotomy, there is little information on longer term outcomes in the year after discharge. The main aim of the study was to assess the impact that an emergency laparotomy has on patients' and employment and health status 1 year after surgery.

METHODS

This study was a questionnaire study conducted in a single centre district general hospital of patients who had undergone an emergency laparotomy between October 2015 and December 2016. Patients were included according to the National Emergency Laparotomy Audit criteria. At screening, patients who were alive at 1 year and had the capacity to consent were approached between January and December 2017. Patients underwent a researcher-led telephone interview using a semi-structured questionnaire to assess the impact of emergency laparotomy on overall, general and physical health (Glasgow Benefit Inventory) as well as employment status. The symptoms that patients experienced and their impact were also recorded.

RESULTS

Forty-two patients responded to and completed the questionnaire. Just over one-third of patients experienced a deterioration in their general or physical health and 21% of patients experienced a change in employment. Factors which significantly impacted on health status were stoma issues, postoperative morbidity and a change in employment (p < 0.05). The main symptoms which patients identified as being troublesome were altered bowel habit and stoma issues with a resultant social and psychological impact.

CONCLUSIONS

One-third of patients experienced a deterioration in their psychosocial and physical health status as well as a change in employment during the first-year postsurgery. Larger research studies are required to define the impact of emergency laparotomy on patients in the longer term and more research is needed to improve perioperative rehabilitation in the postoperative period to ensure optimal functional gain after technically successful surgery.

Shock drives a STAT3 and JunB-mediated coordinated transcriptional and DNA methylation response in the endothelium

Endothelial dysfunction is a crucial factor in promoting organ failure during septic shock. However, the underlying mechanisms are unknown. Here, we show that kidney injury after lipopolysaccharide (LPS) insult leads to strong endothelial transcriptional and epigenetic responses. Furthermore, SOCS3 loss leads to an aggravation of the responses, demonstrating a causal role for the STAT3-SOCS3 signaling axis in the acute endothelial response to LPS. Experiments in cultured endothelial cells demonstrate that IL-6 mediates this response. Furthermore, bioinformatics analysis of in vivo and in vitro transcriptomics and epigenetics suggests a role for STAT, AP1 and interferon regulatory family (IRF) transcription factors. Knockdown of STAT3 or the AP1 member JunB partially prevents the changes in gene expression, demonstrating a role for these transcription factors. In conclusion, endothelial cells respond with a coordinated response that depends on overactivated IL-6 signaling via STAT3, JunB and possibly other transcription factors. Our findings provide evidence for a critical role of IL-6 signaling in regulating shock-induced epigenetic changes and sustained endothelial activation, offering a new therapeutic target to limit vascular dysfunction.

Mental, cognitive and physical outcomes after intensive care unit treatment during the COVID-19 pandemic: a comparison between COVID-19 and non-COVID-19 patients

To compare mental, cognitive and physical outcomes between COVID-19 and non-COVID-19 patients, 3-6 months after Intensive Care Unit (ICU) treatment during the COVID-19 pandemic and to compare mental outcomes between relatives of these patients. This retrospective cohort study included 209 ICU survivors (141 COVID-19 patients and 68 non-COVID-19 patients) and 168 of their relatives (maximum one per patient) during the COVID-19 pandemic. Primary outcomes were self-reported occurrence of mental, cognitive and/or physical symptoms 3-6 months after ICU discharge. The occurrence of mental symptoms did not differ between former COVID-19 patients (34.7% [43/124]) and non-COVID-19 patients (43.5% [27/62]) (p = 0.309), neither between relatives of COVID-19 patients (37.6% [38/101]) and relatives of non-COVID-19 patients (39.6% [21/53]) (p = 0.946). Depression scores on the Hospital Anxiety and Depression Scale were lower in former COVID-19 patients, compared to non-COVID-19 patients (p = 0.025). We found no differences between COVID-19 and non-COVID-19 patients in cognitive and physical outcomes. Mental, cognitive and physical outcomes in COVID-19 ICU survivors were similar to non-COVID-19 ICU survivors. Mental symptoms in relatives of COVID-19 ICU survivors did not differ from relatives of non-COVID-19 ICU survivors, within the same time frame.

A protocol for a pilot randomised controlled trial of an Early Psychiatric Assessment, Referral, and Intervention Study (EPARIS) for intensive care patients

BACKGROUND

Up to 80% of Intensive Care Unit patients experience physical, cognitive, and/or psychological complications post-discharge, known as 'Post Intensive Care Syndrome' (PICS). Early diagnosis and intervention are a priority, but while current post-intensive care follow-up processes endorse a multidisciplinary model, incorporating a psychiatric consultation has not been studied.

METHODS

A pilot, open-label randomised controlled trial was developed by a multidisciplinary team to evaluate the feasibility and acceptability of incorporating a psychiatric review into an existing post-ICU clinic. The study will run for 12 months and aim to recruit 30 participants. Inclusion criteria for participants: a) ICU admission greater than 48 hours, b) no cognitive impairment that prevents participation, c) ≥ 18 years old, d) residing in Australia, e) fluent in English, f) able to provide GP information, and g) likely to be contactable in 6 months. Patient recruitment will be at Redcliffe Hospital, Queensland, Australia, and will involve patients attending the Redcliffe post intensive care clinic. Participants will be allocated to intervention or control using block randomisation and allocation concealment. Participants allocated to the control arm will receive the standard cares provided by the clinic, which involves an unstructured interview about their ICU experience and a battery of surveys about their psychological, cognitive, and physical function. Those allocated to the intervention arm will receive these same cares as well as an appointment with a psychiatrist for a single session intervention. The psychiatric intervention will involve a comprehensive review, including comorbid disorders, substance use, suicidal ideation, psychosocial stressors, social/emotional supports. Psychoeducation and initial treatment will be provided as indicated and recommendations given to the patient and their GP about how to access ongoing care. In addition to surveys conducted as part of standard clinic cares, all participants will complete additional questionnaires about their history, hospital experience, mental and physical health as well as employment circumstances. All participants will be followed up 6 months after their appointment and will be invited to complete follow-up questionnaires about their mental and physical health, as well as health service use and employment circumstances. The trial has been registered with ANZCTR (ACTRN12622000894796).

RESULTS

To evaluate the feasibility and acceptability of the intervention to the patient population. Differences between groups will be assessed using an independent samples t-test. Resource requirements to administer the intervention will be evaluated by reporting the mean duration of the EPARIS assessment and approximate cost per patient to provide this service. To estimate the effect size of any treatment effects, changes in secondary outcome measures between baseline and 6 months will be compared between intervention and control groups using Analysis of Covariance regression. As this is a pilot, we will not use p-values or test a null hypothesis, but will give confidence intervals.

CONCLUSIONS

This protocol provides a pragmatic evaluation of the acceptability of introducing early psychiatric assessment into an existing post-ICU follow-up process, and if considered acceptable will inform future research into the efficacy and generalisability of the intervention. The strengths of EPARIS are the prospective, longitudinal design with a control population, and its use of validated post-ICU outcome measures.

Economic Analysis of Renal Replacement Therapy Modality in Acute Kidney Injury Patients With Fluid Overload

Acute kidney injury (AKI) and fluid overload (FO) are among the top reasons to initiate intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT). Prior research suggests CRRT provides more precise volume control, but whether CRRT is cost-effective remains unclear. We assessed the cost-effectiveness of CRRT for volume control compared with IHD from a U.S. healthcare payer perspective.

DESIGN

Decision analytical model comparing health outcomes and healthcare costs of CRRT versus IHD initiation for AKI patients with FO. The model had an inpatient phase (over 90-d) followed by post-discharge phase (over lifetime). The 90-day phase had three health states: FO, fluid control, and death. After 90 days, surviving patients entered the lifetime phase with four health states: dialysis independent (DI), dialysis dependent (DD), renal transplantation, and death. Model parameters were informed by current literature. Sensitivity analyses were performed to evaluate results robustness to parametric uncertainty.

SETTING

ICU.

PATIENTS OR SUBJECTS

AKI patients with FO.

INTERVENTIONS

IHD or CRRT.

MEASUREMENTS AND MAIN RESULTS

The 90-day horizon revealed better outcomes for patients initiated on CRRT (survival: CRRT 59.2% vs IHD 57.5% and DD rate among survivors: CRRT 5.5% vs IHD 6.9%). Healthcare cost was 2.7% (+$2,836) higher for CRRT. Over lifetime, initial CRRT was associated with +0.313 life years (LYs) and +0.187 quality-adjusted life years (QALYs) compared with initial IHD. Even though important savings were observed for initial CRRT with a lower rate of DD among survivors (-$13,437), it did not fully offset the incremental cost of CRRT (+$1,956) and DI survival (+$12,830). The incremental cost-per-QALY gained with CRRT over IRRT was +$10,429/QALY. Results were robust to sensitivity analyses.

CONCLUSIONS

Our analysis provides an economic rationale for CRRT as the initial modality of choice in AKI patients with FO who require renal replacement therapy. Our finding needs to be confirmed in future research.

Post-intensive care syndrome (PICS): recent updates

An increasing number of patients are surviving critical illness, but some experience new or worsening long-lasting impairments in physical, cognitive and/or mental health, commonly known as post-intensive care syndrome (PICS). The need to better understand and improve PICS has resulted in a growing body of literature exploring its various facets. This narrative review will focus on recent studies evaluating various aspects of PICS, including co-occurrence of specific impairments, subtypes/phenotypes, risk factors/mechanisms, and interventions. In addition, we highlight new aspects of PICS, including long-term fatigue, pain, and unemployment.

Neurorecovery after Critical COVID-19 Illness

With the hundreds of millions of people worldwide who have been, and continue to be, affected by pandemic coronavirus disease (COVID-19) and its chronic sequelae, strategies to improve recovery and rehabilitation from COVID-19 are critical global public health priorities. Neurologic complications have been associated with acute COVID-19 infection, usually in the setting of critical COVID-19 illness. Neurologic complications are also a core feature of the symptom constellation of long COVID and portend poor outcomes. In this article, we review neurologic complications and their mechanisms in critical COVID-19 illness and long COVID. We focus on parallels with neurologic disease associated with non-COVID critical systemic illness. We conclude with a discussion of how recent findings can guide both neurologists working in post-acute neurologic rehabilitation facilities and policy makers who influence neurologic resource allocation.

Effects of COVID-19 Acute Respiratory Distress Syndrome Intensive Care Unit Survivor Telemedicine Clinic on Patient Readmission, Pain Perception, and Self-Assessed Health Scores: Randomized, Prospective, Single-Center, Exploratory Study

BACKGROUND

Post-intensive care syndrome (PICS) affects up to 50% of intensive care unit (ICU) survivors, leading to long-term neurocognitive, psychosocial, and physical impairments. Approximately 80% of COVID-19 pneumonia ICU patients are at elevated risk for developing acute respiratory distress syndrome (ARDS). Survivors of COVID-19 ARDS are at high risk of unanticipated health care utilization postdischarge. This patient group commonly has increased readmission rates, long-term decreased mobility, and poorer outcomes. Most multidisciplinary post-ICU clinics for ICU survivors are in large urban academic medical centers providing in-person consultation. Data are lacking on the feasibility of providing telemedicine post-ICU care for COVID-19 ARDS survivors.

OBJECTIVE

We explored the feasibility of instituting a COVID-19 ARDS ICU survivor telemedicine clinic and examined its effect on health care utilization post-hospital discharge.

METHODS

This randomized, unblinded, single-center, parallel-group, exploratory study was conducted at a rural, academic medical center. Study group (SG) participants underwent a telemedicine visit within 14 days of discharge, during which a 6-minute walk test (6MWT), EuroQoL 5-Dimension (EQ-5D) questionnaire, and vital signs logs were reviewed by an intensivist. Additional appointments were arranged as needed based on the outcome of this review and tests. The control group (CG) underwent a telemedicine visit within 6 weeks of discharge and completed the EQ-5D questionnaire; additional care was provided as needed based on findings in this telemedicine visit.

RESULTS

Both SG (n=20) and CG (n=20) participants had similar baseline characteristics and dropout rate (10%). Among SG participants, 72% (13/18) agreed to pulmonary clinic follow-up, compared with 50% (9/18) of CG participants (P=.31). Unanticipated visits to the emergency department occurred for 11% (2/18) of the SG compared with 6% (1/18) of the CG (>.99). The rate of pain or discomfort was 67% (12/18) in the SG compared with 61% (11/18) in the CG (P=.72). The anxiety or depression rate was 72% (13/18) in the SG versus 61% (11/18; P=.59) in the CG. Participants' mean self-assessed health rating scores were 73.9 (SD 16.1) in the SG compared with 70.6 (SD 20.9) in the CG (P=.59). Both primary care physicians (PCPs) and participants in the SG perceived the telemedicine clinic as a favorable model for postdischarge critical illness follow-up in an open-ended questionnaire regarding care.

CONCLUSIONS

This exploratory study found no statistically significant results in reducing health care utilization postdischarge and health-related quality of life. However, PCPs and patients perceived telemedicine as a feasible and favorable model for postdischarge care among COVID-19 ICU survivors to facilitate expedited subspecialty assessment, decrease unanticipated postdischarge health care utilization, and reduce PICS. Further investigation is warranted to determine the feasibility of incorporating telemedicine-based post-hospitalization follow-up for all medical ICU survivors that may show improvement in health care utilization in a larger population.

Association Between Socioeconomic Status and Outcomes in Critical Care: A Systematic Review and Meta-Analysis

OBJECTIVES

Socioeconomic status is well established as a key determinant of inequalities in health outcomes. Existing literature examining the impact of socioeconomic status on outcomes in critical care has produced inconsistent findings. Our objective was to synthesize the available evidence on the association between socioeconomic status and outcomes in critical care.

DATA SOURCES

A systematic search of CINAHL, Ovid MEDLINE, and EMBASE was undertaken on September 13, 2022.

STUDY SELECTION

Observational cohort studies of adults assessing the association between socioeconomic status and critical care outcomes including mortality, length of stay, and functional outcomes were included. Two independent reviewers assessed titles, abstracts, and full texts against eligibility and quality criteria.

DATA EXTRACTION

Details of study methodology, population, exposure measures, and outcomes were extracted.

DATA SYNTHESIS

Thirty-eight studies met eligibility criteria for systematic review. Twenty-three studies reporting mortality to less than or equal to 30 days following critical care admission, and eight reporting length of stay, were included in meta-analysis. Random-effects pooled analysis showed that lower socioeconomic status was associated with higher mortality at less than or equal to 30 days following critical care admission, with pooled odds ratio of 1.13 (95% CIs, 1.05-1.22). Meta-analysis of ICU length of stay demonstrated no significant difference between socioeconomic groups. Socioeconomic status may also be associated with functional status and discharge destination following ICU admission.

CONCLUSIONS

Lower socioeconomic status was associated with higher mortality following admission to critical care.

Delirium-related psychiatric and neurocognitive impairment and the association with post-intensive care syndrome-A narrative review

INTRODUCTION

Delirium is common among patients admitted to the intensive care unit (ICU) and its impact on the neurocognitive and psychiatric state of survivors is of great interest. These new-onset or worsening conditions, together with physical alterations, are called post-intensive care syndrome (PICS). Our aim is to update on the latest screening and follow-up options for psychological and cognitive sequelae of PICS.

METHOD

This narrative review discusses the occurrence of delirium in ICU settings and the relatively new concept of PICS. Psychiatric and neurocognitive morbidities that may occur in survivors of critical illness following delirium are addressed. Future perspectives for practice and research are discussed.

RESULTS

There is no "gold standard" for diagnosing delirium in the ICU, but two extensively validated tools, the confusion assessment method for the ICU and the intensive care delirium screening checklist, are often used. PICS complaints are frequent in ICU survivors who have suffered delirium and have been recognized as an important public health and socio-economic problem worldwide. Depression, anxiety, post-traumatic stress disorder, and long-term cognitive impairment are recurrently exhibited. Screening tools for these deficits are discussed, as well as the suggestion of early assessment after discharge and at 3 and 12 months.

CONCLUSIONS

Delirium is a complex but common phenomenon in the ICU and a risk factor for PICS. Its diagnosis is challenging with potential long-term adverse outcomes, including psychiatric and cognitive difficulties. The implementation of screening and follow-up protocols for PICS sequelae is warranted to ensure early detection and appropriate management.

Using experience-based co-design to prioritise areas for improvement for patients recovering from critical illness

OBJECTIVES

Critical illness recovery is a journey; from intensive care unit to hospital ward to home. However, evidence is limited on how best to enable recovery from critical illness. This study aimed to prioritise areas for improvement in care and services for patients recovering from critical illness.

RESEARCH DESIGN

This study used experience-based co-design. Service users and providers worked in partnership to identify and prioritise service improvements for patients who had survived an episode of critical illness.

METHOD

Qualitative interviews were carried out with patients (n = 10) who had experienced critical illness, and staff (n = 9) who had experienced caring for patients in the intensive care unit. Key patient touchpoints were identified and used to produce a film, reflecting the critical illness journey. A patient feedback event incorporated an emotional mapping exercise, to identify key points during the recovery journey. A joint patient/family (n = 10) and staff (n = 10) event was held to view the film and identify priorities for improvements.

FINDINGS

Emotional mapping highlighted areas where services were not synchronised with patients' needs. Four patient-focussed priorities for service improvement emerged 1. Improving the critical care experience, 2. Addressing patients' emotional and psychological needs, 3. Positioning patients at the centre of services and 4. Building a supportive framework for recovery.

CONCLUSION

Evidence-based co-design was used successfully in this study to identify priorities for improvements for patients recovering from critical illness. This approach positions patients at the centre of service improvements and realigns care delivery around what matters most to patients. Person-centred care provision underpins all identified priorities.

IMPLICATIONS FOR CLINICAL PRACTICE

Intensive care unit staff should get to know patients and their families by talking more to patients and families about their care and engaging in more non-medical conversations. Emotional and psychological support should be provided to aid rehabilitation and recovery from critical illness in the intensive care unit, on general wards, and in the community. Information and services should be available when patients need them, rather than at fixed time points or settings. Recovery services should focus on enabling and building the self-efficacy of patients to empower them to be in control of their recovery journey.

Return to work during first year after intensive care treatment and the impact of demographic, clinical and psychosocial factors

OBJECTIVES

To describe work participation in survivors during first year after intensive care unit discharge and examine the impact of selected demographic, clinical and psychosocial factors on return to work 12 months after discharge.

RESEARCH METHODOLOGY/DESIGN

A predefined sub-study (prospective cohort study) of a randomised controlled trial.

SETTING

A Norwegian single-centre university hospital. Medical and surgical adult intensive care survivors, working/on sick leave before admission, in the intensive care unit ≥24 h, were included.

MAIN OUTCOME MEASURES

Return to work three, six and 12 months after discharge, and impact of age, pre-existing comorbidities, previous serious life events, coping ability, hope and social support on return to work 12 months after discharge.

RESULTS

Included were 284 patients, with mean age 47 years (SD 13.9) and 47 % women. One year after discharge, 69 % were back at work. In the regression analysis, with working at 12 months (yes/no) as the dependent variable, 178 patients, completing questionnaires at three as well as 12 months, were included. Lower age (OR 0.96, 95 % CI [0.93-0.99]), lower pre-existing comorbidities (OR 0.65, 95 % CI [0.43-0.97]), previous serious life events (OR 6.53, 95 % CI [2.14-19.94]), and greater hope at three months (OR 1.09, 95 % CI [1.01-1.17]) were all independently associated with higher odds of returning to work.

CONCLUSION

Following intensive care, age, pre-existing comorbidities, experience of previous serious life events and hope all have a significant impact on return to work, and are important variables to consider during intensive care treatment and rehabilitation.

IMPLICATIONS FOR CLINICAL PRACTICE

Attention must be paid to patients with prior working capability to ensure return to work after intensive care treatment. Older adults with pre-existing comorbidities might benefit from early, individualised rehabilitation to regain previous working capacity. In addition, there is also a need to support patients' hope during and after critical illness.

A protocol for exploring patients' and support peoples' experiences after prolonged critical illness

BACKGROUND

Improved survival of critically ill people has increased the number of patients who experience an extended stay in intensive care units (ICU). Evidence suggests the complexities, vulnerabilities, and traumas created by critical illness are substantial for both patients and their support people with a number experiencing devastating impairments across multiple domains of health and function including physical, mental, cognitive, and social health. However, research on survivors predominantly focuses on those who have experienced a relatively short length of stay; only a limited number of studies seek to explore the experiences of survivors and their support people who have had a prolonged stay in intensive care.

AIMS AND OBJECTIVES

To describe the experiences of survivors of prolonged critical illness (invasively mechanically ventilated in ICU for ≥eight days) and their support people during the first 12 months following hospital discharge in New Zealand.

DESIGN

This research will be a multi-centre study recruiting from three intensive care units in New Zealand. A narrative inquiry methodology will be used to interview 6-8 former long stay patients and 6-8 support people of a former long stay patient. Each participant will be interviewed at 3-, 6-, 9-, and 12-months following hospital discharge.

METHODS

Data will be collected via narrative inquiry interviews. Data analysis will combine two theoretical frameworks: the Clandinin and Connelly narrative inquiry three-dimensional space and the Fairclough situation, discourse and context framework.

RESULTS

The phenomenon of investigation will be experiences after prolonged critical illness explored longitudinally across the first-year post-hospital discharge.

RELEVANCE TO CLINICAL PRACTICE

This protocol provides a methodological framework for exploring the lived experiences of survivors of prolonged critical illness and their support people. Data analysis will support understanding of the human journey of ICU survivorship and add to the body of knowledge on how to support post-ICU recovery in this population. The barriers and enablers of survivorship at the micro, meso, and macro levels of the health service will also be illuminated.

The economic burden and long-term mortality in survivors of extracorporeal membrane oxygenation in South Korea

Background

The economic burden for extracorporeal membrane oxygenation (ECMO) survivors is a critical issue. We investigated the total healthcare costs for one year following ECMO support and its association with three-year all-cause mortality.

Methods

This population-based cohort study used data from the National Health Insurance Service (NHIS) in South Korea. Adult ECMO survivors (age ≥18 years who were alive ≥365 days following ECMO support) from January 1, 2005, to December 31, 2018, were included. The total healthcare costs for one year included all the expenses for hospital and outpatient clinic visits after discharge.

Results

In total, 6,044 patients were included in the final analysis comprising 3,566 (59.0%) in the cardiac indication group, 658 (10.9%) in the respiratory indication group, and 1,820 (30.1%) in the "other" group. The median total healthcare cost was United States Dollars (USD) 46,308.0 [interquartile range (IQR): 25,727.0-86,924.8]. The median ECMO support and hospital stay durations were three (IQR: 1-7) days and 25 (IQR: 15-31) days. In the multivariable Cox regression model, a USD 1,000 increase in the total healthcare cost was associated with an increase in the three-year all-cause mortality (hazard ratio, 1.01; 95% CI: 1.00-1.01; P=0.015).

Conclusions

After one year, ECMO survivors accrued USD 46,308 in healthcare costs in South Korea. An increase in the total healthcare cost was associated with a higher risk of three-year all-cause mortality among ECMO survivors.

High rates of impaired quality of life and social and economic problems at 6 months after COVID-19-related ARDS

Purpose

Assess long-term quality of life (HR-QoL) and socio-economic impact in COVID-19-related ARDS (C-ARDS) survivors.

Methods

C-ARDS survivors were followed up at 6 months in this prospective, cohort study. HR-QoL was assessed using SF-36 and EQ-5D-5L, and the socio-economic burden of COVID-19 was evaluated with a dedicated questionnaire. Clinical data were prospectively recorded.

Results

Seventy-nine survivors, age 63 [57-71], 84% male, were enrolled. The frequency of EQ-5D-5L reported problems was significantly higher among survivors compared to normal, in mobility, usual activities, and self-care; anxiety and depression and pain were not different. SF-36 scores were lower than the reference population, and physical and mental summary scores were below normal in 52% and 33% of the subjects, respectively. In the multivariable analysis, prolonged hospital length of stay (OR 1.45; p 0.02) and two or more comorbidities on admission (OR 7.42; p 0.002) were significant predictors of impaired “physical” and “mental” HR-QoL, respectively. A total of 38% subjects worsened social relations, 42% changed their employment status, and 23% required personal care support.

Conclusions

C-ARDS survivors have long-term impairment in HR-QoL and socio-economic problems. Prolonged hospital stay and previous comorbidities are risk factors for developing health-related issues.

Supplementary Information

The online version contains supplementary material available at. 10.1186/s44158-022-00048-5

A Step Forward for Intensive Care Unit Patients: Early Mobility Interventions and Associated Outcome Measures

Background

Critical illness survivors have impairments across physical, psychological, and cognitive health domains known as post–intensive care syndrome. Although physical activity can improve outcomes across all health domains, most intensive care unit early mobility studies focus solely on physical outcomes.

Objective

To explore the role of early mobility for adult patients in the intensive care unit by analyzing early mobility intervention studies with physical, psychological, or cognitive outcome measures.

Methods

This integrative review used Whittemore and Knafl’s methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. CINAHL, Embase, PubMed, PsycINFO, and Scopus databases were searched for primary research articles published from 2005 through 2021 on adult intensive care unit early mobility interventions evaluated by physical, cognitive, or psychological outcome measures during or after intervention delivery. Interventions comprising only passive mobility were excluded.

Results

Of 1009 articles screened, 20 were included. Variations in outcome measures, measurement timing, instruments, and control groups made synthesis difficult. No study evaluated an intervention using outcome measures from all 3 health domains. Five studies measured physical and cognitive outcomes; 6 studies measured physical and psychological outcomes.

Conclusion

Early mobility is primarily addressed objectively and unidimensionally, limiting understanding of the implications of early mobility for patients. Post–intensive care syndrome prevention begins in the intensive care unit; early mobility is a promising intervention for targeting multiple risk factors. Studies that measure outcomes in all health domains during or after early mobility are needed to better evaluate the comprehensive effects of early mobility.

Instruments to measure postintensive care syndrome: a scoping review protocol

INTRODUCTION

There is an increasing need for evaluating postintensive care syndrome in adults concerning their long-term physical, psychological, cognitive and/or social outcomes, yet there is no consensus regarding the choice of instruments to measure these. This scoping review aims to identify and examine instruments used to measure postintensive care syndrome in adults.

METHODS AND ANALYSIS

This scoping review will be conducted following the Arksey and O'Malley and its extended framework, and the Joanna Briggs Institute guideline. It will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Review checklists. Medline via EBSCO, CINAHL complete, EMBASE, Web of Science, AME and APA PsycINFO databases and grey literature will be searched from 2010 to the present. Reference lists of included studies will be manually checked to identify additional sources. The quality of included studies will be appraised using the Crowe Critical Appraisal Tool. All review steps will involve at least two reviewers. Data charting will be performed narratively, comprising study characteristics and findings, and instrument properties. This review will also aim to identify research gaps.

ETHICS AND DISSEMINATION

There is no ethics disclosure for this review protocol. This scoping review will identify instruments used to measure postintensive care syndrome in adults. The findings will be disseminated through professional bodies, conferences and research papers.

Return to work after discharge from the intensive care unit: a Brazilian multicenter cohort

OBJECTIVE

To describe the rate and factors related to nonreturn to work in the third month after discharge from the intensive care unit and the impact of unemployment, loss of income and health care expenses for survivors.

METHODS

This was a prospective multicenter cohort study that included survivors of severe acute illness who were hospitalized between 2015 and 2018, previously employed, and who stayed more than 72 hours in the intensive care unit. Outcomes were assessed by telephone interview in the third month after discharge.

RESULTS

Of the 316 patients included in the study who had previously worked, 193 (61.1%) did not return to work within 3 months after discharge from the intensive care unit. The following factors were associated with nonreturn to work: low educational level (prevalence ratio 1.39; 95%CI 1.10 - 1.74; p = 0.006), previous employment relationship (prevalence ratio 1.32; 95%CI 1 10 - 1.58; p = 0.003), need for mechanical ventilation (prevalence ratio 1.20; 95%CI 1.01 - 1.42; p = 0.04) and physical dependence in the third month after discharge (prevalence ratio 1.27; 95%CI 1.08 - 1.48; p = 0.003). Survivors who were unable to return to work more often had reduced family income (49.7% versus 33.3%; p = 0.008) and increased health expenditures (66.9% versus 48.3%; p = 0.002). compared to those who returned to work in the third month after discharge from the intensive care unit.

CONCLUSION

Intensive care unit survivors often do not return to work until the third month after discharge from the intensive care unit. Low educational level, formal job, need for ventilatory support and physical dependence in the third month after discharge were related to nonreturn to work. Failure to return to work was also associated with reduced family income and increased health care costs after discharge.

Social determinants of recovery

PURPOSE OF REVIEW

The purpose of this review is to examine evidence describing the influence of social determinants on recovery following hospitalization with critical illness. In addition, it is meant to provide insight into the several mechanisms through which social factors influence recovery as well as illuminate approaches to addressing these factors at various levels in research, clinical care, and policy.

RECENT FINDINGS

Social determinants of health, ranging from individual factors like social support and socioeconomic status to contextual ones like neighborhood deprivation, are associated with disability, cognitive impairment, and mental health after critical illness. Furthermore, many social factors are reciprocally related to recovery wherein the consequences of critical illness such as financial toxicity and caregiver burden can put essential social needs under strain turning them into barriers to recovery.

SUMMARY

Recovery after hospitalization for critical illness may be influenced by many social factors. These factors warrant attention by clinicians, health systems, and policymakers to enhance long-term outcomes of critical illness survivors.

Modification of social determinants of health by critical illness and consequences of that modification for recovery: an international qualitative study

OBJECTIVES

Social determinants of health (SDoH) contribute to health outcomes. We identified SDoH that were modified by critical illness, and the effect of such modifications on recovery from critical illness.

DESIGN

In-depth semistructured interviews following hospital discharge. Interview transcripts were mapped against a pre-existing social policy framework: money and work; skills and education; housing, transport and neighbourhoods; and family, friends and social connections.

SETTING

14 hospital sites in the USA, UK and Australia.

PARTICIPANTS

Patients and caregivers, who had been admitted to critical care from three continents.

RESULTS

86 interviews were analysed (66 patients and 20 caregivers). SDoH, both financial and non-financial in nature, could be negatively influenced by exposure to critical illness, with a direct impact on health-related outcomes at an individual level. Financial modifications included changes to employment status due to critical illness-related disability, alongside changes to income and insurance status. Negative health impacts included the inability to access essential healthcare and an increase in mental health problems.

CONCLUSIONS

Critical illness appears to modify SDoH for survivors and their family members, potentially impacting recovery and health. Our findings suggest that increased attention to issues such as one's social network, economic security and access to healthcare is required following discharge from critical care.

Supporting Decision-Making About Patient Mobility in the Intensive Care Unit Nurse Work Environment: Work Domain Analysis

Background

Patient mobility is an evidenced-based physical activity intervention initiated during intensive care unit (ICU) admission and continued throughout hospitalization to maintain functional status, yet mobility is a complex intervention and not consistently implemented. Cognitive work analysis (CWA) is a useful human factors framework for understanding complex systems and can inform future technology design to optimize outcomes.

Objective

The aim of this study is to understand the complexity and constraints of the ICU work environment as it relates to nurses carrying out patient mobility interventions, using CWA.

Methods

We conducted a work domain analysis and completed an abstraction hierarchy using the CWA framework. Data from documents, observation (32 hours), and interviews with nurses (N=20) from 2 hospitals were used to construct the abstraction hierarchy.

Results

Nurses seek information from a variety of sources and integrate patient and unit information to inform decision-making. The completed abstraction hierarchy depicts multiple high-level priorities that nurses balance, specifically, providing quality, safe care to patients while helping to manage unit-level throughput needs. Connections between levels on the abstraction hierarchy describe how and why nurses seek patient and hospital unit information to inform mobility decision-making. The analysis identifies several opportunities for technology design to support nurse decision-making about patient mobility.

Conclusions

Future interventions need to consider the complexity of the ICU environment and types of information nurses need to make decisions about patient mobility. Considerations for future system redesign include developing and testing clinical decision support tools that integrate critical patient and unit-level information to support nurses in making patient mobility decisions.

The role of nutrition rehabilitation in the recovery of survivors of critical illness: underrecognized and underappreciated

Many survivors of critical illness face significant physical and psychological disability following discharge from the intensive care unit (ICU). They are often malnourished, a condition associated with poor outcomes, and nutrition remains problematic particularly in the early phases of ICU recovery. Yet nutrition rehabilitation, the process of restoring or optimizing nutritional status following illness, is seldom prioritized, possibly because it is an underrecognized and underappreciated area in critical care rehabilitation and research. To date, 16 original studies have been published where one of the objectives includes measurement of indices relating to nutritional status (e.g., nutrition intake or factors impacting nutrition intake) in ICU survivors. The primary aim of this narrative review is to provide a comprehensive summary of key themes arising from these studies which form the basis of our current understanding of nutritional recovery and rehabilitation in ICU survivors. ICU survivors face a multitude of barriers in achieving optimal nutrition that are of physiological (e.g., poor appetite and early satiety), functional (e.g., dysphagia, reduced ability to feed independently), and psychological (e.g., low mood, body dysmorphia) origins. Organizational-related barriers such as inappropriate feeding times and meal interruptions frequently impact an ICU survivor’s ability to eat. Healthcare providers working on wards frequently lack knowledge of the specific needs of recovering critically ill patients which can negatively impact post-ICU nutrition care. Unsurprisingly, nutrition intake is largely inadequate following ICU discharge, with the largest deficits occurring in those who have had enteral nutrition prematurely discontinued and rely on an oral diet as their only source of nutrition. With consideration to themes arising from this review, pragmatic strategies to improve nutrition rehabilitation are explored and directions for future research in the field of post-ICU nutrition recovery and rehabilitation are discussed. Given the interplay between nutrition and physical and psychological health, it is imperative that enhancing the nutritional status of an ICU survivor is considered when developing multidisciplinary rehabilitation strategies. It must also be recognized that dietitians are experts in the field of nutrition and should be included in stakeholder meetings that aim to enhance ICU rehabilitation strategies and improve outcomes for survivors of critical illness.

Establishing a Cardiac ICU Recovery Clinic: Characterizing a Model for Continuity of Cardiac Critical Care

BACKGROUND

Care in the cardiovascular intensive care unit (CICU) has become increasingly intricate due to a temporal rise in noncardiac diagnoses and overall clinical complexity with high risk for short-term rehospitalization and mortality. Survivors of critical illness are often faced with debility and limitations extending beyond the index hospitalization. Comprehensive ICU recovery programs have demonstrated some efficacy but have primarily targeted survivors of acute respiratory distress syndrome or sepsis. The efficacy of dedicated ICU recovery programs on the CICU population is not defined.

METHODS

We aim to describe the design and initial experience of a novel CICU-recovery clinic (CICURC). The primary outcome was death or rehospitalization in the first 30 days following hospital discharge. Self-reported outcome measures were performed to assess symptom burden and independence in activities of daily living.

RESULTS

Using standardized criteria, 41 patients were referred to CICURC of which 78.1% established care and were followed for a median of 88 (56-122) days. On intake, patients reported a high burden of heart failure symptoms (KCCQ overall summary score 29.8 [18.0-47.5]), and nearly half (46.4%) were dependent on caretakers for activities of daily living. Thirty days postdischarge, no deaths were observed and the rate of rehospitalization for any cause was 12.2%.

CONCLUSIONS

CICU survivors are faced with significant residual symptom burden, dependence upon caretakers, and impairments in mental health. Dedicated CICURCs may help prioritize treatment of ICU related illness, reduce symptom burden, and improve outcomes. Interventions delivered in ICU recovery clinic for patients surviving the CICU warrant further investigation.

A systematic review of the effect of early mobilization on length of stay for adults in the intensive care unit

BACKGROUND

EM has been hypothesized to help prevent the development of ICU acquired weakness and may therefore result in positive outcomes for ICU patients.

AIM

To establish the impact of Early mobilization (EM) on adult Intensive Care Unit (ICU) patients in terms of ICU length of stay (LOS), as well as hospital LOS, duration of mechanical ventilation, mortality, and functional independence.

STUDY DESIGN

Systematic Review.

METHODS

EMBASE, MEDLINE, CINAHL, and the Cochrane Library were searched on 24th November 2020. Included studies and other systematic reviews were hand-searched for further includable studies. The primary outcome was ICU LOS whilst secondary outcomes were duration of MV, mortality, hospital LOS and functional independence. The PRISMA guidelines were utilized to perform the review. Ten randomized controlled trials with a combined total of 1291 patients met inclusion criteria and were scrutinized using the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews. Revman 5.4.1 was used to conduct meta-analysis were possible.

RESULTS

Results were limited by the evidence available for inclusion, in particular small sample sizes. However, a trend towards a shorter duration of ICU LOS and duration of mechanical ventilation emerged. There was also a trend towards higher rates of functional independence for intervention groups. Mortality rates appeared unaffected and results of meta-analysis were statistically non-significant (p = 0.90).

CONCLUSIONS

By applying a stricter time limit than previous systematic reviews a trend emerged that the commencement of EM has a positive effect on patient outcomes, in particular ICU LOS.

RELEVANCE TO CLINICAL PRACTICE

The evidence base surrounding EM remains poor; however on the balance of the available evidence the application of EM should not be delayed.

Effects on health-related quality of life of interventions affecting survival in critically ill patients: a systematic review

Survival has been considered the cornerstone for clinical outcome evaluation in critically ill patients admitted to intensive care unit (ICU). There is evidence that ICU survivors commonly show impairments in long-term outcomes such as quality of life (QoL) considering them as the most relevant ones. In the last years, the concept of patient-important outcomes has been introduced and increasingly reported in peer-reviewed publications. In the present systematic review, we evaluated how many randomized controlled trials (RCTs) were conducted on critically ill patients and reporting a benefit on survival reported also data on QoL. All RCTs investigating nonsurgical interventions that significantly reduced mortality in critically ill patients were searched on MEDLINE/PubMed, Scopus and Embase from inception until August 2021. In a second stage, for all the included studies, the outcome QoL was investigated. The primary outcome was to evaluate how many RCTs analyzing interventions reducing mortality reported also data on QoL. The secondary endpoint was to investigate if QoL resulted improved, worsened or not modified. Data on QoL were reported as evaluated outcome in 7 of the 239 studies (2.9%). The tools to evaluate QoL and QoL time points were heterogeneous. Four interventions showed a significant impact on QoL: Two interventions improved survival and QoL (pravastatin in subarachnoid hemorrhage, dexmedetomidine in elderly patients after noncardiac surgery), while two interventions reduced mortality but negatively influenced QoL (caloric restriction in patients with refeeding syndrome and systematic ICU admission in elderly patients). In conclusion, only a minority of RCTs in which an intervention demonstrated to affect mortality in critically ill patients reported also data on QoL. Future research in critical care should include patient-important outcomes like QoL besides mortality. Data on this topic should be collected in conformity with PROs statement and core outcome sets to guarantee quality and comparability of results.

Improving physical function of patients following intensive care unit admission (EMPRESS): protocol of a randomised controlled feasibility trial

INTRODUCTION

Physical rehabilitation delivered early following admission to the intensive care unit (ICU) has the potential to improve short-term and long-term outcomes. The use of supine cycling together with other rehabilitation techniques has potential as a method of introducing rehabilitation earlier in the patient journey. The aim of the study is to determine the feasibility of delivering the designed protocol of a randomised clinical trial comparing a protocolised early rehabilitation programme including cycling with usual care. This feasibility study will inform a larger multicentre study.

METHODS AND ANALYSIS

90 acute care medical patients from two mixed medical-surgical ICUs will be recruited. We will include ventilated patients within 72 hours of initiation of mechanical ventilation and expected to be ventilated a further 48 hours or more. Patients will receive usual care or usual care plus two 30 min rehabilitation sessions 5 days/week.Feasibility outcomes are (1) recruitment of one to two patients per month per site; (2) protocol fidelity with >75% of patients commencing interventions within 72 hours of mechanical ventilation, with >70% interventions delivered; and (3) blinded outcome measures recorded at three time points in >80% of patients. Secondary outcomes are (1) strength and function, the Physical Function ICU Test-scored measured on ICU discharge; (2) hospital length of stay; and (3) mental health and physical ability at 3 months using the WHO Disability Assessment Schedule 2. An economic analysis using hospital health services data reported with an embedded health economic study will collect and assess economic and quality of life data including the Hospital Anxiety and Depression Scales core, the Euroqol-5 Dimension-5 Level and the Impact of Event Score.

ETHICS AND DISSEMINATION

The study has ethical approval from the South Central Hampshire A Research Ethics Committee (19/SC/0016). All amendments will be approved by this committee. An independent trial monitoring committee is overseeing the study. Results will be made available to critical care survivors, their caregivers, the critical care societies and other researchers.

TRIAL REGISTRATION NUMBER

NCT03771014.

Acute kidney injury contributes to worse physical and quality of life outcomes in survivors of critical illness

Objectives

Survivors of critical illness and acute kidney injury (AKI) are at risk of increased morbidity. The purpose of this study was to compare physical, emotional, and cognitive health in survivors of critical illness with and without AKI.

Methods

Retrospective cohort study of adult (≥ 18 years old) survivors of critical illness due to sepsis and/or acute respiratory failure who attended follow-up in a specialized ICU Recovery Clinic. Outcomes were evaluated during 3-month visit and comprised validated tests for evaluation of physical function, muscle strength, cognitive and emotional health, and self-reported health-related quality of life (HRQOL). Descriptive statistics and group comparisons were performed.

Results

A total of 104 patients with median age of 55 [49-64] years, 54% male, and median SOFA score of 10 [8-12] were analyzed. Incidence of AKI during ICU admission was 61 and 19.2% of patients required renal replacement therapy (RRT). Patients with AKI stage 2 or 3 (vs. those with AKI stage 1 or no AKI) walked less on the 6-min walk test (223 ± 132 vs. 295 ± 153 m, p = 0.059) and achieved lower of the predicted walk distance (38% vs. 58%, p = 0.041). Similar patterns of worse physical function and more significant muscle weakness were observed in multiple tests, with overall worse metrics in patients that required RRT. Patients with AKI stage 2 or 3 also reported lower HRQOL scores when compared to their counterparts, including less ability to return to work or hobby, or reengage in driving. There were no significant differences in cognitive function or emotional health between groups.

Conclusions

Survivors of critical illness and AKI stage 2 or 3 have increased physical debility and overall lower quality of life, with more impairment in return to work, hobby, and driving when compared to their counterparts without AKI or AKI stage 1 at 3 months post-discharge.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02749-z.