1
|
Rodrigues AR, Oliveira A, Vieira T, Assis R, Lume C, Gonçalves-Pereira J, Fernandes SM. A prolonged intensive care unit stay defines a worse long-term prognosis - Insights from the critically ill mortality by age (Cimba) study. Aust Crit Care 2024:S1036-7314(24)00048-1. [PMID: 38649316 DOI: 10.1016/j.aucc.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 01/11/2024] [Accepted: 03/02/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Patients with critical illness often survive the intensive care unit (ICU) at a cost of prolonged length of stay (LOS) and slow recovery. This chronic critically ill disease may lead to long-term poor outcomes, especially in older or frail patients. OBJECTIVES The main goal of this study was to address the characteristics and outcomes of patients with prolonged ICU LOS. Mainly, short- and long-term admissions were compared to identify risk factors for persistent critical illness and to characterise the impact on ICU, hospital, and long-term mortality. METHODS Subanalysis of a retrospective, multicentric, observational study addressing the 2-year outcome of patients admitted to Portuguese ICUs (the Cimba study). Patients were segregated according to an ICU LOS of ≥14 days. RESULTS Data from 37 118 patients were analysed, featuring a median ICU LOS of 4 days (percentile: 25-75 2-9), and a mortality of 16.1% in the ICU, 24.0% in the hospital, and 38.7% after 2 years. A total of 5334 patients (14.4%) had an ICU LOS of ≥14 days (corresponding to 48.9% of all ICU patients/days). Patients with prolonged LOS were more often younger (52.8% vs 46.4%, were ≤65 years of age , p < 0.001), although more severe (Simplified Acute Physiology Score II: 49.1 ± 16.9 vs 41.8 ± 19.5, p < 0.001), and had higher ICU and hospital mortality (18.3% vs 15.7%, and 31.2 vs 22.8%, respectively). Prolonged ICU LOS was linked to an increased risk of dying during the 2-year follow-up (adjusted Cox proportional hazard: 1.65, p < 0.001). CONCLUSION Prolonged LOS is associated with a long-term impact on patient prognosis. More careful planning of care should incorporate these data.
Collapse
Affiliation(s)
- Ana Rita Rodrigues
- Clinica Universitária de Medicina Intensiva, FMUL, Lisbon, Portugal; Intensive Care Department, Hospital St(a) Maria, Lisbon, Portugal
| | - André Oliveira
- Intensive Care Unit, Hospital de Vila Franca Xira, EPE, Portugal
| | - Tatiana Vieira
- Intensive Care Department, Hospital de São João, Porto, Portugal
| | - Rui Assis
- Intensive Care Unit, Centro Hospitalar Médio Tejo, Abrantes, Portugal
| | - Catarina Lume
- Intensive Care Unit, Hospital Nélio Mendonça, Funchal, Portugal
| | - João Gonçalves-Pereira
- Clinica Universitária de Medicina Intensiva, FMUL, Lisbon, Portugal; Intensive Care Unit, Hospital de Vila Franca Xira, EPE, Portugal; Grupo Infeção e Desenvolvimento em Sépsis (GIS-ID), Porto, Portugal
| | - Susana M Fernandes
- Clinica Universitária de Medicina Intensiva, FMUL, Lisbon, Portugal; Intensive Care Department, Hospital St(a) Maria, Lisbon, Portugal; Grupo Infeção e Desenvolvimento em Sépsis (GIS-ID), Porto, Portugal.
| |
Collapse
|
2
|
Villalba D, Navarro E, Matesa A, Brusco A, Morales V, Morel Vulliez GG, Rositi ES, Prieto L, Bosso MJ, De Paoli S, Cotero A, Nadur J, Santini M, Alonso M, Larocca F, Duarte C, García V, Campodónico R, Musso G, Leingruber M, Morales AS, Segura A, Vallory ME, Pieruzzi SDC, Pascal PS, De Vito EL. Epidemiology of Tracheostomized Adult Patients Admitted to Specialized Weaning Centers After Acute COVID-19. Respir Care 2024; 69:202-209. [PMID: 37963609 PMCID: PMC10898473 DOI: 10.4187/respcare.11113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
BACKGROUND Epidemiological data on patients with COVID-19 referred to specialized weaning centers (SWCs) are sparse, particularly in low- and middle-income countries. Our aim was to describe clinical features, epidemiology, and outcomes of subjects admitted to SWCs in Argentina. METHODS We conducted a prospective, multi-center, observational study between July 2020-December 2021 in 12 SWCs. We collected demographic characteristics, laboratory results, pulmonary function, and dependence on mechanical ventilation at admission, decannulation, weaning from mechanical ventilation, and status at discharge. A multiple logistic model was built to predict home discharge. RESULTS We enrolled 568 tracheostomized adult subjects after the acute COVID-19 phase who were transferred to SWCs. Age was 62 [52-71], males 70%, Charlson comorbidity index was 2 [0-3], and length of stay in ICU was 42 [32-56] d. Of the 315 ventilator-dependent subjects, 72.4% were weaned, 427 (75.2%) were decannulated, and 366 subjects (64.5%) were discharged home. The mortality rate was 6.0%. In multivariate analysis, age (odds ratio 0.30 [95% CI 0.16-0.56], P < .001), Charlson comorbidity index (odds ratio 0.43 [95% CI 0.22-0.84], P < .01), mechanical ventilation duration in ICU (odds ratio 0.80 [95% CI 0.72-0.89], P < .001), renal failure (odds ratio 0.40 [95% CI 0.22-0.73], P = .003), and expiratory muscle weakness (odds ratio 0.35 [95% CI 0.19-0.62], P < .001) were independently associated with home discharge. CONCLUSIONS Most subjects with COVID-19 transferred to SWCs were weaned, achieved decannulation, and were discharged to home. Age, high-comorbidity burden, prolonged mechanical ventilation in ICU, renal failure at admission, and expiratory muscle weakness were inversely associated with home discharge.
Collapse
Affiliation(s)
- Dario Villalba
- Clínica Basilea, Ciudad Autónoma de Buenos Aires, Argentina.
| | | | - Amelia Matesa
- Clínica Basilea, Ciudad Autónoma de Buenos Aires, Argentina
| | - Andrés Brusco
- AlCla/Clínica de Rehabilitación Integral, Ciudad Autónoma de Buenos Aires, Argentina
| | - Virginia Morales
- AlCla/Clínica de Rehabilitación Integral, Ciudad Autónoma de Buenos Aires, Argentina
| | | | | | - Luciana Prieto
- Santa Catalina, Ciudad Autónoma de Buenos Aires, Argentina
| | | | | | - Alejo Cotero
- CIAREC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Juan Nadur
- CIAREC, Ciudad Autónoma de Buenos Aires, Argentina
| | | | | | | | | | | | | | - Gabriel Musso
- Centro Integral de Rehabilitación APREPA, San Jerónimo Sud, Argentina
| | - Mariel Leingruber
- Centro Integral de Rehabilitación APREPA, San Jerónimo Sud, Argentina
| | | | | | | | | | | | | |
Collapse
|
3
|
Sánchez-Arguiano MJ, Miñambres E, Cuenca-Fito E, Suberviola B, Burón-Mediavilla FJ, Ballesteros MA. Chronic critical illness after trauma injury: outcomes and experience in a trauma center. Acta Chir Belg 2023; 123:618-624. [PMID: 35881765 DOI: 10.1080/00015458.2022.2106626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 07/23/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To determine the prevalence, risk factors and functional results of chronic critical illness (CCI) in polytrauma patients. DESIGN Single-center observational retrospective study. SETTING ICU at a tertiary hospital in Santander, Spain, between 2015 and 2019. PATIENTS Adult trauma patients who survived beyond 48 h after injury. CCI was defined as the need for mechanical ventilation for at least 14 days or tracheostomy for difficult weaning. MEASUREMENTS AND MAIN RESULTS About 62/575 developed CCI. These patients were characterized by higher ISS score [17 (SD 10) vs. 13.8 (SD 8.2); p < 0.001] and higher NISS (26 (SD 11) vs. 19.2 (SD 10.5); p = 0.001). CCI group had greater proportion of hospital-acquired infections (100% vs. 18.1%; p < 0.001), and acute kidney failure (33.9% vs. 22.8% p < 0.001). During the first 24 h of admission, CCI group required in a greater proportion surgical intervention (50% vs. 29%; p = 0.001), and blood products (31.3% vs. 20.5%; p < 0.047). Hospital ward stay was longer in CCI patients [9.5 days (IQR 5-16.9) vs. 43.9 (IQR 30.3-53) p < 0.001]. The CCI mortality was higher (19.5% vs. 8.1%; p = 0.004). Surgical intervention in the first 24 h (OR 2.5 95% CI 1.1-4.1), age (> 55 years) (OR 2.1 95%CI 1.1-4.2), ISS score (OR 1.1 95%CI 1.02-1.3), GCS score (OR 0.8 95%CI 0.4-23.2) and multiple organ failure (OR 9.5 95%CI 3.9-23.2) were predictors of CCI in the multivariate analysis. CONCLUSIONS CCI after severe trauma appears in a considerable proportion of patients. Early identification and implementation of specific interventions could change the evolution of this process.
Collapse
Affiliation(s)
| | - Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - Elena Cuenca-Fito
- Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Borja Suberviola
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | | | - María A Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| |
Collapse
|
4
|
Yildirim S, Durmaz Y, Şan Y, Taşkıran İ, Cinleti BA, Kirakli C. Cost of Chronic Critically Ill Patients to the Healthcare System: A Single-center Experience from a Developing Country. Indian J Crit Care Med 2021; 25:519-523. [PMID: 34177170 PMCID: PMC8196383 DOI: 10.5005/jp-journals-10071-23804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background An increasing number of patients become chronic critically ill (CCI) and dependent on long-term therapies in the intensive care unit (ICU). Mortality and healthcare costs increase in these patients. In order to deal with this problem, the magnitude and risk factors for CCI must first be determined. Therefore, we aimed at evaluating the incidence cost and risk factors for CCI in our ICU. Materials and methods This retrospective cohort study was compiled by recruiting patients admitted to our ICU between January 1, 2017, and December 31, 2018. Patients with an ICU stay of more than 21 days were defined as CCI. Patients who did not survive in the first 21 days were excluded from the study because it could be not known whether these patients would progress to CCI. During the study period, 1,166 patients were followed up, and 475 (40%) of them were excluded and 691 patients were included in the final analyses. Results During the study period, 691 patients were included in the study and 152 of them (22%) were CCI. Age, acute physiology and chronic health evaluation (APACHE)-2 score, length of stay, and daily costs were higher in patients with CCI. The cost for a patient with CCI is sixfold that of a patient without CCI. ICU mortality was 47% in patients without CCI and 54% in the CCI patients (p < 0.001). Conclusion CCI affects an increasing number of patients and leads to increased mortality rates and cost. Prolonged duration in ICU may cause complications such as secondary infections, sepsis episodes, and acute renal injury. The treatment of these complications may lead to increased mortality and cost. How to cite this article Yildirim S, Durmaz Y, Şan Y, Taşkiran İ, Cinleti BA, Kirakli C. Cost of Chronic Critically Ill Patients to the Healthcare System: A Single-center Experience from a Developing Country. Indian J Crit Care Med 2021;25(5):519–523.
Collapse
Affiliation(s)
- Süleyman Yildirim
- Department of Intensive Care Unit, University of Health Sciences, Turkey, Dr Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, İzmir, Turkey
| | - Yusuf Durmaz
- Department of Intensive Care Unit, Hakkari Public Hospital, Hakkari, Turkey
| | - Yosun Şan
- Department of Intensive Care Unit, University of Health Sciences, Turkey, Dr Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, İzmir, Turkey
| | - İmren Taşkıran
- Department of Intensive Care Unit, University of Health Sciences, Turkey, Dr Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, İzmir, Turkey
| | - Burcu A Cinleti
- Department of Intensive Care Unit, University of Health Sciences, Turkey, Dr Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, İzmir, Turkey
| | - Cenk Kirakli
- Department of Intensive Care Unit, University of Health Sciences, Turkey, Dr Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, İzmir, Turkey
| |
Collapse
|
5
|
Aguiar FP, Westphal GA, Dadam MM, Mota ECC, Pfutzenreuter F, França PHC. Characteristics and predictors of chronic critical illness in the intensive care unit. Rev Bras Ter Intensiva 2020; 31:511-520. [PMID: 31967226 PMCID: PMC7009003 DOI: 10.5935/0103-507x.20190088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 07/11/2019] [Indexed: 12/17/2022] Open
Abstract
Objective To characterize patients with chronic critical illness and identify predictors of development of chronic critical illness. Methods Prospective data was collected for 1 year in the intensive care unit of a general hospital in Southern Brazil. Three logistic regression models were constructed to identify factors associated with chronic critical illness. Results Among the 574 subjects admitted to the intensive care unit, 200 were submitted to mechanical ventilation. Of these patients, 85 (43.5%) developed chronic critical illness, composing 14.8% of all the patients admitted to the intensive care unit. The regression model that evaluated the association of chronic critical illness with conditions present prior to intensive care unit admission identified chronic renal failure in patients undergoing hemodialysis (OR 3.57; p = 0.04) and a neurological diagnosis at hospital admission (OR 2.25; p = 0.008) as independent factors. In the model that evaluated the association of chronic critical illness with situations that occurred during intensive care unit stay, muscle weakness (OR 2.86; p = 0.01) and pressure ulcers (OR 9.54; p < 0.001) had the strongest associations. In the global multivariate analysis (that assessed previous factors and situations that occurred in the intensive care unit), hospital admission due to neurological diseases (OR 2.61; p = 0.03) and the development of pressure ulcers (OR 9.08; p < 0.001) had the strongest associations. Conclusion The incidence of chronic critical illness in this study was similar to that observed in other studies and had a strong association with the diagnosis of neurological diseases at hospital admission and chronic renal failure in patients undergoing hemodialysis, as well as complications developed during hospitalization, such as pressure ulcers and muscle weakness.
Collapse
Affiliation(s)
- Fernanda Perito Aguiar
- Programa de Pós-Graduação em Saúde e Meio Ambiente e Departamento de Medicina, Universidade da Região de Joinville - Joinville (SC), Brasil.,Unidade de Terapia Intensiva, Hospital São José - Joinville (SC), Brasil
| | - Glauco Adrieno Westphal
- Programa de Pós-Graduação em Saúde e Meio Ambiente e Departamento de Medicina, Universidade da Região de Joinville - Joinville (SC), Brasil.,Unidade de Terapia Intensiva, Hospital São José - Joinville (SC), Brasil
| | | | - Elisa Cristina Correia Mota
- Programa de Pós-Graduação em Saúde e Meio Ambiente e Departamento de Medicina, Universidade da Região de Joinville - Joinville (SC), Brasil
| | | | - Paulo Henrique Condeixa França
- Programa de Pós-Graduação em Saúde e Meio Ambiente e Departamento de Medicina, Universidade da Região de Joinville - Joinville (SC), Brasil
| |
Collapse
|
6
|
Lalueza A, Folgueira D, Muñoz-Gallego I, Trujillo H, Laureiro J, Hernández-Jiménez P, Moral-Jiménez N, Castillo C, Ayuso B, Díaz-Pedroche C, Torres M, Arrieta E, Arévalo-Cañas C, Madrid O, Lumbreras C. Influence of viral load in the outcome of hospitalized patients with influenza virus infection. Eur J Clin Microbiol Infect Dis 2019; 38:667-673. [PMID: 30820840 PMCID: PMC7102091 DOI: 10.1007/s10096-019-03514-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/14/2019] [Indexed: 01/30/2023]
Abstract
The role of viral load in the outcome of patients requiring hospital admission due to influenza is not well established. We aim to assess if there is an association between the viral load and the outcome in hospitalized patients with a confirmed influenza virus infection. A retrospective observational study including all adult patients who were hospitalized in our center with a confirmed influenza virus infection from January to May 2016. Viral load was measured by real-time reverse-transcriptase–polymerase chain reaction (rRT-PCR) cycle threshold (Ct) value on upper respiratory tract samples. Its value was categorized into three groups (low Ct, ≤ 20; intermediate Ct, > 20–30; and high Ct, > 30). Two hundred thirty-nine patients were included. Influenza A/H1N1pdm09 was isolated in 207 cases (86.6%). The mean Ct value was 26.69 ± 5.81. The viral load was higher in the unvaccinated group when compared with the vaccinated patients (Ct 25.17 ± 5.55 vs. 27.58 ± 4.97, p = 0.004). Only 27 patients (11.29%) presented a high viral load. Patients with a high viral load more often showed abnormal findings on chest X-ray (p = 0.015) and lymphopenia (p = 0.097). By contrast, there were no differences between the three groups (according to viral load), in associated pneumonia, respiratory failure, need for mechanical ventilation, sepsis, or in-hospital mortality. Our findings suggest that in patients admitted to the hospital with confirmed influenza virus infection (mostly A/H1N1pdm09), a high viral load is associated with a higher presence of abnormal findings on chest X-ray but not with a significant worse prognosis. In these cases, standardized quantitative PCR could be useful.
Collapse
Affiliation(s)
- Antonio Lalueza
- Department of Internal Medicine, University Hospital 12 de Octubre, Av. Córdoba km 5400, 28041, Madrid, Spain. .,Department of Medicine, School of Medicine, Complutense University, Madrid, Spain. .,Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain.
| | - Dolores Folgueira
- Department of Medicine, School of Medicine, Complutense University, Madrid, Spain.,Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain.,Department of Microbiology, University Hospital 12 de Octubre, Madrid, Spain
| | - Irene Muñoz-Gallego
- Department of Microbiology, University Hospital 12 de Octubre, Madrid, Spain
| | - Hernando Trujillo
- Department of Internal Medicine, University Hospital 12 de Octubre, Av. Córdoba km 5400, 28041, Madrid, Spain
| | - Jaime Laureiro
- Department of Internal Medicine, University Hospital 12 de Octubre, Av. Córdoba km 5400, 28041, Madrid, Spain
| | - Pilar Hernández-Jiménez
- Department of Internal Medicine, University Hospital 12 de Octubre, Av. Córdoba km 5400, 28041, Madrid, Spain
| | | | - Cristina Castillo
- Department of Internal Medicine, University Hospital 12 de Octubre, Av. Córdoba km 5400, 28041, Madrid, Spain
| | - Blanca Ayuso
- Department of Internal Medicine, University Hospital 12 de Octubre, Av. Córdoba km 5400, 28041, Madrid, Spain
| | - Carmen Díaz-Pedroche
- Department of Internal Medicine, University Hospital 12 de Octubre, Av. Córdoba km 5400, 28041, Madrid, Spain.,Department of Medicine, School of Medicine, Complutense University, Madrid, Spain
| | - Marta Torres
- Department of Internal Medicine, University Hospital 12 de Octubre, Av. Córdoba km 5400, 28041, Madrid, Spain
| | - Estibaliz Arrieta
- Department of Internal Medicine, University Hospital 12 de Octubre, Av. Córdoba km 5400, 28041, Madrid, Spain
| | - Coral Arévalo-Cañas
- Department of Internal Medicine, University Hospital 12 de Octubre, Av. Córdoba km 5400, 28041, Madrid, Spain
| | - Olaya Madrid
- Department of Internal Medicine, University Hospital 12 de Octubre, Av. Córdoba km 5400, 28041, Madrid, Spain
| | - Carlos Lumbreras
- Department of Internal Medicine, University Hospital 12 de Octubre, Av. Córdoba km 5400, 28041, Madrid, Spain.,Department of Medicine, School of Medicine, Complutense University, Madrid, Spain.,Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain.,Infectious Diseases Unit, University Hospital 12 de Octubre, Madrid, Spain
| |
Collapse
|
7
|
Chiang SR, Lai CC, Ho CH, Chen CM, Chao CM, Wang JJ, Cheng KC. Prolonged Mechanical Ventilation Assistance Interacts Synergistically with Carbapenem for Clostridium difficile Infection in Critically Ill Patients. J Clin Med 2018; 7:jcm7080224. [PMID: 30127264 PMCID: PMC6111739 DOI: 10.3390/jcm7080224] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/11/2018] [Accepted: 08/19/2018] [Indexed: 12/18/2022] Open
Abstract
Objectives: Interactions between mechanical ventilation (MV) and carbapenem interventions were investigated for the risk of Clostridium difficile infection (CDI) in critically ill patients undergoing concurrent carbapenem therapy. Methods: Taiwan’s National Intensive Care Unit Database (NICUD) was used in this analytical, observational, and retrospective study. We analyzed 267,871 intubated patients in subgroups based on the duration of MV support: 7–14 days (n = 97,525), 15–21 days (n = 52,068), 22–28 days (n = 35,264), and 29–60 days (n = 70,021). The primary outcome was CDI. Results: Age (>75 years old), prolonged MV assistance (>21 days), carbapenem therapy (>15 days), and high comorbidity scores were identified as independent risk factors for developing CDI. CDI risk increased with longer MV support. The highest rate of CDI was in the MV 29–60 days subgroup (adjusted hazard ratio (AHR) = 2.85; 95% confidence interval (CI) = 1.46–5.58; p < 0.02). Moreover, higher CDI rates correlated with the interaction between MV and carbapenem interventions; these CDI risks were increased in the MV 15–21 days (AHR = 2.58; 95% CI = 1.12–5.91) and MV 29–60 days (AHR = 4.63; 95% CI = 1.14–10.03) subgroups than in the non-MV and non-carbapenem subgroups. Conclusions: Both MV support and carbapenem interventions significantly increase the risk that critically ill patients will develop CDI. Moreover, prolonged MV support and carbapenem therapy synergistically induce CDI. These findings provide new insights into the role of MV support in the development of CDI.
Collapse
Affiliation(s)
- Shyh-Ren Chiang
- Department of Internal Medicine, Chi Mei Medical Center, 71004 Tainan, Taiwan.
- Department of General Education, Chia Nan University of Pharmacy and Science, 71710 Tainan, Taiwan.
| | - Chih-Cheng Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, 73657 Liouying, Taiwan.
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, 71004 Tainan, Taiwan.
- Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, 71710 Tainan, Taiwan.
| | - Chin-Ming Chen
- Department of Intensive Care Medicine, Chi Mei Medical Center, 71004 Tainan, Taiwan.
- Departments of Recreation and Healthcare Management, Chia Nan University of Pharmacy and Science, 71710 Tainan, Taiwan.
| | - Chien-Ming Chao
- Department of Intensive Care Medicine, Chi Mei Medical Center, 73657 Liouying, Taiwan.
| | - Jhi-Joung Wang
- Department of Medical Research, Chi Mei Medical Center, 71004 Tainan, Taiwan.
| | - Kuo-Chen Cheng
- Department of Internal Medicine, Chi Mei Medical Center, 71004 Tainan, Taiwan.
- Department of Safety, Health, and Environmental Engineering, Chung Hwa University of Medical Technology, 71703 Tainan, Taiwan.
| |
Collapse
|
8
|
Loss SH, Nunes DSL, Franzosi OS, Salazar GS, Teixeira C, Vieira SRR. Chronic critical illness: are we saving patients or creating victims? Rev Bras Ter Intensiva 2018; 29:87-95. [PMID: 28444077 PMCID: PMC5385990 DOI: 10.5935/0103-507x.20170013] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 09/05/2016] [Indexed: 12/15/2022] Open
Abstract
The technological advancements that allow support for organ dysfunction have led
to an increase in survival rates for the most critically ill patients. Some of
these patients survive the initial acute critical condition but continue to
suffer from organ dysfunction and remain in an inflammatory state for long
periods of time. This group of critically ill patients has been described since
the 1980s and has had different diagnostic criteria over the years. These
patients are known to have lengthy hospital stays, undergo significant
alterations in muscle and bone metabolism, show immunodeficiency, consume
substantial health resources, have reduced functional and cognitive capacity
after discharge, create a sizable workload for caregivers, and present high
long-term mortality rates. The aim of this review is to report on the most
current evidence in terms of the definition, pathophysiology, clinical
manifestations, treatment, and prognosis of persistent critical illness.
Collapse
Affiliation(s)
- Sergio Henrique Loss
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil
| | - Diego Silva Leite Nunes
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Oellen Stuani Franzosi
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Departamento de Nutrição, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil
| | | | - Cassiano Teixeira
- Faculdade de Medicina, Universidade Federal de Ciências da Saúde de Porto Alegre - Porto Alegre (RS), Brasil
| | - Silvia Regina Rios Vieira
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil.,Departamento de Clínica Médica, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| |
Collapse
|
9
|
Impact of severe hematological abnormalities in the outcome of hospitalized patients with influenza virus infection. Eur J Clin Microbiol Infect Dis 2017; 36:1827-1837. [PMID: 28500507 PMCID: PMC7101956 DOI: 10.1007/s10096-017-2998-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/21/2017] [Indexed: 12/16/2022]
Abstract
Although hematological abnormalities have been described among patients with influenza virus infection, little is known about their impact on the outcome of the patients. The aim of this study was to assess the frequency and clinical impact of severe hematological abnormalities in patients with confirmed influenza virus infection. This was an observational retrospective study including all adult patients with diagnosis of influenza virus infection hospitalized from January to May 2016 in our institution. Influenza virus infection was diagnosed by means of rRT-PCR assay performed on respiratory samples. Poor outcome was defined as a composite endpoint in which at least one of the following criteria had to be fulfilled: (a) respiratory failure, (b) SOFA ≥2, or (c) death. Two hundred thirty-nine patients were included. Applying the HLH-04 criteria for the diagnosis of hemophagocytic syndrome, cytopenias (hemoglobin ≤9 g/dl, platelets <100,000/μl or neutrophils <1,000/μl) were present in 51 patients (21%). Patients with hematological abnormalities showed higher SOFA scores, respiratory failure, septic shock and in-hospital mortality than the remaining patients. The composite endpoint was present in 33.3% in the cytopenias group vs. 13.3% in the group without cytopenias (p=0.001). In a multivariate analysis, variables associated with the composite endpoint were: use of steroids prior to present admission (OR: 0.12; 95% CI: 0.015–0.96, p=0.046), presence of any hematological abnormality (OR: 3.54; 95% CI:1.66–7.51, p= 0.001), and LDH>225 U/l (OR:4.45; CI:1–19.71, p=0.049). Hematological abnormalities are not uncommon among hospitalized patients with influenza virus infection, and they are associated with a poorer outcome.
Collapse
|
10
|
Abstract
OBJECTIVES To evaluate the association between length of ICU stay and 1-year mortality for elderly patients who survived to hospital discharge in the United States. DESIGN Retrospective cohort study of a random sample of Medicare beneficiaries who survived to hospital discharge, with 1- and 3-year follow-up, stratified by the number of days of intensive care and with additional stratification based on receipt of mechanical ventilation. INTERVENTIONS None. PATIENTS The cohort included 34,696 Medicare beneficiaries older than 65 years who received intensive care and survived to hospital discharge in 2005. MEASUREMENTS AND MAIN RESULTS Among 34,696 patients who survived to hospital discharge, the mean ICU length of stay was 3.4 days (± 4.5 d). Patients (88.9%) were in the ICU for 1-6 days, representing 58.6% of ICU bed-days. Patients (1.3%) were in the ICU for 21 or more days, but these patients used 11.6% of bed-days. The percentage of mechanically ventilated patients increased with increasing length of stay (6.3% for 1-6 d in the ICU and 71.3% for ≥ 21 d). One-year mortality was 26.6%, ranging from 19.4% for patients in the ICU for 1 day, up to 57.8% for patients in the ICU for 21 or more days. For each day beyond 7 days in the ICU, there was an increased odds of death by 1 year of 1.04 (95% CI, 1.03-1.05) irrespective of the need for mechanical ventilation. CONCLUSIONS Increasing ICU length of stay is associated with higher 1-year mortality for both mechanically ventilated and non-mechanically ventilated patients. No specific cutoff was associated with a clear plateau or sharp increase in long-term risk.
Collapse
|
11
|
Bugedo G, Egal M, Bakker J. Prolonged mechanical ventilation and chronic critical illness. J Thorac Dis 2016; 8:751-3. [PMID: 27162644 DOI: 10.21037/jtd.2016.03.60] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Guillermo Bugedo
- 1 Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile ; 2 Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, the Netherlands ; 3 Division of Pulmonary, Allergy and Critical Care, Department of Medicine, College of Physicians & Surgeons of Columbia University, New York, NY, USA
| | - Mohamud Egal
- 1 Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile ; 2 Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, the Netherlands ; 3 Division of Pulmonary, Allergy and Critical Care, Department of Medicine, College of Physicians & Surgeons of Columbia University, New York, NY, USA
| | - Jan Bakker
- 1 Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile ; 2 Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, the Netherlands ; 3 Division of Pulmonary, Allergy and Critical Care, Department of Medicine, College of Physicians & Surgeons of Columbia University, New York, NY, USA
| |
Collapse
|
12
|
Boniatti MM, Giustina AD, Marin LG, França J, Dos Santos MC, Vidart J, Pellegrini JAS, Lincho CS, Rodrigues Filho EM. Mortality in chronically critically ill patients: Expanding the use of the ProVent score. J Crit Care 2015; 30:1039-42. [PMID: 26169543 DOI: 10.1016/j.jcrc.2015.06.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 06/19/2015] [Accepted: 06/23/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of the study is to look at the performance of the Prognosis for Prolonged Ventilation (ProVent) score with a short-term outcome as well as when used earlier during the course of prolonged mechanical ventilation (MV). MATERIALS AND METHODS This retrospective study was performed in a tertiary public hospital from August 2011 to August 2012. All patients admitted to the intensive care unit (ICU) during this period were included in the study. Chronically critically ill (CCI) patients were defined as those with 21 days of MV. In a subsequent analysis, we considered CCI patients to be those with 14 days of MV. The data were collected in 2 ways: review of a prospectively elaborated database and review of electronic records. RESULTS During the study period, 1360 patients were admitted to the ICU. Of these, 152 patients (11.2%) were considered CCI. Patients with high ProVent score presented higher ICU mortality. Mortality ranged from 25.0% for patients with a score of 0 to 84.0% for patients with a score of greater than or equal to 4. The analysis of the ProVent score performed earlier during the evolution (14 days of MV) was similar. CONCLUSIONS The ProVent score can be used for short-term prognosis (mortality in the ICU) and earlier in the evaluation of CCI patients.
Collapse
Affiliation(s)
| | - Andreia Della Giustina
- Internal Medicine Department, Hospital Nossa Senhora da Conceição, Porto Alegre, RS, Brazil.
| | - Luiz Gustavo Marin
- Critical Care Department, Hospital Nossa Senhora da Conceição, Porto Alegre, RS, Brazil.
| | - Josiane França
- Critical Care Department, Hospital Nossa Senhora da Conceição, Porto Alegre, RS, Brazil.
| | | | - Josi Vidart
- Critical Care Department, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.
| | | | - Carla Silva Lincho
- Critical Care Department, Hospital Nossa Senhora da Conceição, Porto Alegre, RS, Brazil.
| | | |
Collapse
|
13
|
Das Neves AV, Vasquez DN, Loudet CI, Intile D, Sáenz MG, Marchena C, Gonzalez AL, Moreira J, Reina R, Estenssoro E. Symptom burden and health-related quality of life among intensive care unit survivors in Argentina: A prospective cohort study. J Crit Care 2015; 30:1049-54. [PMID: 26105747 DOI: 10.1016/j.jcrc.2015.05.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 04/11/2015] [Accepted: 05/23/2015] [Indexed: 11/16/2022]
Abstract
PURPOSE Our goal was to describe the evolution of selected physical and psychologic symptoms and identify the determinants of health-related quality of life (HRQOL) after intensive care unit (ICU) discharge. METHODS The study is a prospective cohort of consecutive adult patients admitted to a mixed ICU in a university-affiliated hospital, mechanically ventilated for more than 48 hours. During ICU stay, epidemiological data and events probably associated to worsening outcomes were recorded. After discharge, patients were interviewed at 1, 3, 6, and 12 months. Health-related quality of life was assessed with EuroQoL Questionnaire-5 Dimensions, which includes the EQ-index and EQ-Visual Analogue Scale. RESULTS One hundred twelve patients were followed up, aged 33 [24-49] years, 68% male, 76% previously healthy, and cranial trauma was the main diagnosis. Physical and psychologic symptoms and moderate/severe problems according to the EQ index progressively decreased after discharge, yet were still highly prevalent after 1 year. EQ index improved from 0.22 [0.01-0.69] to 0.52 [0.08-0.81], 0.66 [0.17-0.79], and 0.68 [0.26-0.86] (P < .001, for all vs month 1). EQ-Visual Analogue Scale remained stable, within acceptable values. Independent determinants of EQ-index were time, duration of mechanical ventilation, shock, weakness, and return to study/work. CONCLUSIONS Determinants of HRQOL after ICU discharge were both related to late sequelae of critical illness and to some events occurring in the ICU. Notwithstanding the high symptom burden, patients still perceived their HRQOL as good.
Collapse
Affiliation(s)
- Andrea V Das Neves
- Servicio de Terapia Intensiva, Hospital Interzonal General de Agudos San Martin de La Plata 1 y 70, 1900 La Plata, Buenos Aires, Argentina
| | - Daniela N Vasquez
- Servicio de Terapia Intensiva, Sanatorio Anchorena, Tomas de Anchorena, C1425ELP, 1872 Ciudad Autónoma de Buenos Aires, Argentina
| | - Cecilia I Loudet
- Servicio de Terapia Intensiva, Hospital Interzonal General de Agudos San Martin de La Plata 1 y 70, 1900 La Plata, Buenos Aires, Argentina
| | - Dante Intile
- Servicio de Terapia Intensiva, Sanatorio Anchorena, Tomas de Anchorena, C1425ELP, 1872 Ciudad Autónoma de Buenos Aires, Argentina
| | - María Gabriela Sáenz
- Servicio de Terapia Intensiva, Hospital Interzonal General de Agudos San Martin de La Plata 1 y 70, 1900 La Plata, Buenos Aires, Argentina
| | - Cecilia Marchena
- Servicio de Terapia Intensiva, Hospital Interzonal General de Agudos San Martin de La Plata 1 y 70, 1900 La Plata, Buenos Aires, Argentina
| | - Ana L Gonzalez
- Servicio de Terapia Intensiva, Hospital Interzonal General de Agudos San Martin de La Plata 1 y 70, 1900 La Plata, Buenos Aires, Argentina
| | - Joaquin Moreira
- Instituto del Diagnostico, 62 n° 370, 1900 La Plata, Buenos Aires, Argentina
| | - Rosa Reina
- Servicio de Terapia Intensiva, Hospital Interzonal General de Agudos San Martin de La Plata 1 y 70, 1900 La Plata, Buenos Aires, Argentina
| | - Elisa Estenssoro
- Servicio de Terapia Intensiva, Hospital Interzonal General de Agudos San Martin de La Plata 1 y 70, 1900 La Plata, Buenos Aires, Argentina.
| |
Collapse
|
14
|
Loss SH, de Oliveira RP, Maccari JG, Savi A, Boniatti MM, Hetzel MP, Dallegrave DM, Balzano PDC, Oliveira ES, Höher JA, Torelly AP, Teixeira C. The reality of patients requiring prolonged mechanical ventilation: a multicenter study. Rev Bras Ter Intensiva 2015; 27:26-35. [PMID: 25909310 PMCID: PMC4396894 DOI: 10.5935/0103-507x.20150006] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 01/20/2015] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE The number of patients who require prolonged mechanical ventilation increased during the last decade, which generated a large population of chronically ill patients. This study established the incidence of prolonged mechanical ventilation in four intensive care units and reported different characteristics, hospital outcomes, and the impact of costs and services of prolonged mechanical ventilation patients (mechanical ventilation dependency ≥ 21 days) compared with non-prolonged mechanical ventilation patients (mechanical ventilation dependency < 21 days). METHODS This study was a multicenter cohort study of all patients who were admitted to four intensive care units. The main outcome measures were length of stay in the intensive care unit, hospital, complications during intensive care unit stay, and intensive care unit and hospital mortality. RESULTS There were 5,287 admissions to the intensive care units during study period. Some of these patients (41.5%) needed ventilatory support (n = 2,197), and 218 of the patients met criteria for prolonged mechanical ventilation (9.9%). Some complications developed during intensive care unit stay, such as muscle weakness, pressure ulcers, bacterial nosocomial sepsis, candidemia, pulmonary embolism, and hyperactive delirium, were associated with a significantly higher risk of prolonged mechanical ventilation. Prolonged mechanical ventilation patients had a significant increase in intensive care unit mortality (absolute difference = 14.2%, p < 0.001) and hospital mortality (absolute difference = 19.1%, p < 0.001). The prolonged mechanical ventilation group spent more days in the hospital after intensive care unit discharge (26.9 ± 29.3 versus 10.3 ± 20.4 days, p < 0.001) with higher costs. CONCLUSION The classification of chronically critically ill patients according to the definition of prolonged mechanical ventilation adopted by our study (mechanical ventilation dependency ≥ 21 days) identified patients with a high risk for complications during intensive care unit stay, longer intensive care unit and hospital stays, high death rates, and higher costs.
Collapse
Affiliation(s)
- Sérgio Henrique Loss
- Departamento de Terapia Intensiva, Hospital Mãe de Deus, Porto Alegre, RS, Brasil
| | | | | | - Augusto Savi
- Departamento de Terapia Intensiva, Hospital Moinhos de Vento, Porto Alegre, RS, Brasil
| | | | - Márcio Pereira Hetzel
- Departamento de Terapia Intensiva, Unidade Central de Terapia Intensiva, Hospital Irmandade Santa Casa de Porto Alegre, Porto Alegre, RS, Brasil
| | - Daniele Munaretto Dallegrave
- Departamento de Terapia Intensiva, Unidade Central de Terapia Intensiva, Hospital Irmandade Santa Casa de Porto Alegre, Porto Alegre, RS, Brasil
| | | | | | - Jorge Amilton Höher
- Departamento de Terapia Intensiva, Unidade Central de Terapia Intensiva, Hospital Irmandade Santa Casa de Porto Alegre, Porto Alegre, RS, Brasil
| | - André Peretti Torelly
- Departamento de Terapia Intensiva, Unidade de Terapia Intensiva Santa Rita, Hospital Irmandade Santa Casa de Porto Alegre, Porto Alegre, RS, Brasil
| | - Cassiano Teixeira
- Departamento de Terapia Intensiva, Hospital Moinhos de Vento, Porto Alegre, RS, Brasil
| |
Collapse
|
15
|
Functional variants regulating LGALS1 (Galectin 1) expression affect human susceptibility to influenza A(H7N9). Sci Rep 2015; 5:8517. [PMID: 25687228 PMCID: PMC4649671 DOI: 10.1038/srep08517] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 01/21/2015] [Indexed: 01/01/2023] Open
Abstract
The fatality of avian influenza A(H7N9) infection in humans was over 30%. To identify human genetic susceptibility to A(H7N9) infection, we performed a genome-wide association study (GWAS) involving 102 A(H7N9) patients and 106 heavily-exposed healthy poultry workers, a sample size critically restricted by the small number of human A(H7N9) cases. To tackle the stringent significance cutoff of GWAS, we utilized an artificial imputation program SnipSnip to improve the association signals. In single-SNP analysis, one of the top SNPs was rs13057866 of LGALS1. The artificial imputation (AI) identified three non-genotyped causal variants, which can be represented by three anchor/partner SNP pairs rs13057866/rs9622682 (AI P = 1.81 × 10−7), rs4820294/rs2899292 (2.13 × 10−7) and rs62236673/rs2899292 (4.25 × 10−7) respectively. Haplotype analysis of rs4820294 and rs2899292 could simulate the signal of a causal variant. The rs4820294/rs2899292 haplotype GG, in association with protection from A(H7N9) infection (OR = 0.26, P = 5.92 × 10−7) correlated to significantly higher levels of LGALS1 mRNA (P = 0.050) and protein expression (P = 0.025) in lymphoblast cell lines. Additionally, rs4820294 was mapped as an eQTL in human primary monocytes and lung tissues. In conclusion, functional variants of LGALS1 causing the expression variations are contributable to the differential susceptibility to influenza A(H7N9).
Collapse
|
16
|
Rubio RDC. El enfermo crónico en la fase final de su enfermedad en Cuidado Intensivo requiere la transición del cuidado curativo al cuidado paliativo. Revisión de la literatura. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.acci.2015.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
17
|
Liu X, Zhang Y, Xu X, Du W, Su K, Zhu C, Chen Y, Lei S, Zheng S, Jiang J, Yang S, Guo J, Shao L, Yang Q, Chen J, Li L. Evaluation of plasma exchange and continuous veno-venous hemofiltration for the treatment of severe avian influenza A (H7N9): a cohort study. Ther Apher Dial 2014; 19:178-84. [PMID: 25363618 DOI: 10.1111/1744-9987.12240] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Avian influenza A (H7N9) is a severe disease with high mortality. Hypercytokinemia is thought to play an important role in the pathogenesis. This study was to investigate the efficiency of plasma exchange (PE) + continuous veno-venous hemofiltration (CVVH) on the removal of inflammatory mediators and their benefits in the management of fluid overload and metabolic disturbance. In total, 40 H7N9-infected patients were admitted to our hospital. Sixteen critically ill H7N9-infected patients received combination of PE and CVVH. Data from these 16 patients were collected and analyzed. The effects of PE + CVVH on plasma cytokine/chemokine levels and clinical outcomes were examined. H7N9-infected patients had increased plasma levels compared to healthy controls. After 3 h of PE + CVVH treatment, the cytokine/chemokine levels descended remarkably to lower levels and were maintained thereafter. PE + CVVH also benefited the management of fluid, cardiovascular dysfunction and metabolic disturbance. Of the 16 critically ill patients who received PE + CVVH, 10 patients survived. PE + CVVH decreased the plasma cytokine/chemokine levels significantly. PE + CVVH were also beneficial to the management of severe avian influenza A (H7N9).
Collapse
Affiliation(s)
- Xiaoli Liu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Davis J, Crawford K, Wierman H, Osgood W, Cavanaugh J, Smith KA, Mette S, Orff S. Mobilization of ventilated older adults. J Geriatr Phys Ther 2014; 36:162-8. [PMID: 23478395 DOI: 10.1519/jpt.0b013e31828836e7] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Recent studies of ventilated, critically ill patients have shown early mobilization to be safe and resulting in better functional outcomes at discharge but have not focused on older adults. OBJECTIVES The objectives of this pilot study were to examine the feasibility of and to describe functional outcomes associated with providing early mobilization to critically ill, older adult patients. METHODS This is a prospective cohort study that took place in the medical and surgical intensive care units of a tertiary, academic medical center. Participants were aged 65 years or older, were on mechanical ventilation for 72 or more hours, and had a preadmission Barthel Index score of 70 or greater. Patients with an open ventriculostomy, continuous hemodialysis, or hospitalization of 7 or more days prior to intubation were excluded. A standardized early mobilization protocol was applied by a trained physical and occupational therapist to eligible participants according to previously published guidelines. Demographic information, hospitalization data, RAND 36-Item Short Form Health Survey (SF-36), and Barthel Index scores from preadmission, hospital discharge, and 30-day follow-up were collected. RESULTS Patients who survived to hospital discharge compared with nonsurvivors were similar in their admission and hospital stay demographics. Survivors reported significantly higher functioning than nonsurvivors on preadmission functional status on both the physical functioning and general health RAND SF-36 subscales. Nonsurvivors reported significantly lower physical functioning, general health, vitality, and mental health on preadmission function when compared with the published normative RAND SF-36 data for patients aged 75 years and older. Patients who did survive hospitalization reported significantly more bodily pain at 30-day follow-up than the published normative data. Patients met criteria for therapy 92% of planned interventions, 99% of those sessions were completed, and adverse events occurred in less than 1% of interventions. CONCLUSION Overall results indicate the feasibility and safety of implementing an early mobilization program to critically ill older adult patients.
Collapse
Affiliation(s)
- Josaleen Davis
- 1Maine Medical Center, Portland, Maine. 2University of New England Department of Physical Therapy, University of New England, Biddeford, Maine. 3Allina Health Systems, Minneapolis, Minnesota
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Chen Y, Liang W, Yang S, Wu N, Gao H, Sheng J, Yao H, Wo J, Fang Q, Cui D, Li Y, Yao X, Zhang Y, Wu H, Zheng S, Diao H, Xia S, Zhang Y, Chan KH, Tsoi HW, Teng JLL, Song W, Wang P, Lau SY, Zheng M, Chan JFW, To KKW, Chen H, Li L, Yuen KY. Human infections with the emerging avian influenza A H7N9 virus from wet market poultry: clinical analysis and characterisation of viral genome. Lancet 2013; 381:1916-25. [PMID: 23623390 PMCID: PMC7134567 DOI: 10.1016/s0140-6736(13)60903-4] [Citation(s) in RCA: 661] [Impact Index Per Article: 60.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Human infection with avian influenza A H7N9 virus emerged in eastern China in February, 2013, and has been associated with exposure to poultry. We report the clinical and microbiological features of patients infected with influenza A H7N9 virus and compare genomic features of the human virus with those of the virus in market poultry in Zhejiang, China. METHODS Between March 7 and April 8, 2013, we included hospital inpatients if they had new-onset respiratory symptoms, unexplained radiographic infiltrate, and laboratory-confirmed H7N9 virus infection. We recorded histories and results of haematological, biochemical, radiological, and microbiological investigations. We took throat and sputum samples, used RT-PCR to detect M, H7, and N9 genes, and cultured samples in Madin-Darby canine kidney cells. We tested for co-infections and monitored serum concentrations of six cytokines and chemokines. We collected cloacal swabs from 86 birds from epidemiologically linked wet markets and inoculated embryonated chicken eggs with the samples. We identified and subtyped isolates by RT-PCR sequencing. RNA extraction, complementary DNA synthesis, and PCR sequencing were done for one human and one chicken isolate. We characterised and phylogenetically analysed the eight gene segments of the viruses in the patient's and the chicken's isolates, and constructed phylogenetic trees of H, N, PB2, and NS genes. FINDINGS We identified four patients (mean age 56 years), all of whom had contact with poultry 3-8 days before disease onset. They presented with fever and rapidly progressive pneumonia that did not respond to antibiotics. Patients were leucopenic and lymphopenic, and had impaired liver or renal function, substantially increased serum cytokine or chemokine concentrations, and disseminated intravascular coagulation with disease progression. Two patients died. Sputum specimens were more likely to test positive for the H7N9 virus than were samples from throat swabs. The viral isolate from the patient was closely similar to that from an epidemiologically linked market chicken. All viral gene segments were of avian origin. The H7 of the isolated viruses was closest to that of the H7N3 virus from domestic ducks in Zhejiang, whereas the N9 was closest to that of the wild bird H7N9 virus in South Korea. We noted Gln226Leu and Gly186Val substitutions in human virus H7 (associated with increased affinity for α-2,6-linked sialic acid receptors) and the PB2 Asp701Asn mutation (associated with mammalian adaptation). Ser31Asn mutation, which is associated with adamantane resistance, was noted in viral M2. INTERPRETATION Cross species poultry-to-person transmission of this new reassortant H7N9 virus is associated with severe pneumonia and multiorgan dysfunction in human beings. Monitoring of the viral evolution and further study of disease pathogenesis will improve disease management, epidemic control, and pandemic preparedness. FUNDING Larry Chi-Kin Yung, National Key Program for Infectious Diseases of China.
Collapse
Affiliation(s)
- Yu Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Weifeng Liang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Shigui Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Nanping Wu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Hainv Gao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Jifang Sheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Hangping Yao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Jianer Wo
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Qiang Fang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Dawei Cui
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | | | - Xing Yao
- Huzhou Central Hospital, Huzhou, China
| | - Yuntao Zhang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Haibo Wu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Shufa Zheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hongyan Diao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Shichang Xia
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Yanjun Zhang
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Kwok-Hung Chan
- State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Hoi-Wah Tsoi
- State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Jade Lee-Lee Teng
- State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Wenjun Song
- State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Pui Wang
- State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Siu-Ying Lau
- State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Min Zheng
- State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Jasper Fuk-Woo Chan
- State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Kelvin Kai-Wang To
- State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Honglin Chen
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
- State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
- Correspondence to: Prof Lanjuan Li, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, China
| | - Kwok-Yung Yuen
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
- State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, University of Hong Kong, Hong Kong Special Administrative Region, China
| |
Collapse
|
20
|
Loss SH, Marchese CB, Boniatti MM, Wawrzeniak IC, Oliveira RP, Nunes LN, Victorino JA. Prediction of chronic critical illness in a general intensive care unit. Rev Assoc Med Bras (1992) 2013; 59:241-7. [PMID: 23680275 DOI: 10.1016/j.ramb.2012.12.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 10/29/2012] [Accepted: 12/03/2012] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To assess the incidence, costs, and mortality associated with chronic critical illness (CCI), and to identify clinical predictors of CCI in a general intensive care unit. METHODS This was a prospective observational cohort study. All patients receiving supportive treatment for over 20 days were considered chronically critically ill and eligible for the study. After applying the exclusion criteria, 453 patients were analyzed. RESULTS There was an 11% incidence of CCI. Total length of hospital stay, costs, and mortality were significantly higher among patients with CCI. Mechanical ventilation, sepsis, Glasgow score <15, inadequate calorie intake, and higher body mass index were independent predictors for CCI in the multivariate logistic regression model. CONCLUSIONS CCI affects a distinctive population in intensive care units with higher mortality, costs, and prolonged hospitalization. Factors identifiable at the time of admission or during the first week in the intensive care unit can be used to predict CCI.
Collapse
Affiliation(s)
- Sérgio H Loss
- Department of Critical Care Medicine, Hospital de Clínicas, Porto Alegre, RS, Brazil.
| | | | | | | | | | | | | |
Collapse
|
21
|
Theodorou VP, Papaioannou VE, Tripsianis GA, Panopoulou MK, Christophoridis EK, Kouliatsis GA, Gioka TM, Maltezos ES, Ktenidou-Kartali SI, Pneumatikos IA. Procalcitonin and procalcitonin kinetics for diagnosis and prognosis of intravascular catheter-related bloodstream infections in selected critically ill patients: a prospective observational study. BMC Infect Dis 2012; 12:247. [PMID: 23043618 PMCID: PMC3502591 DOI: 10.1186/1471-2334-12-247] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 09/20/2012] [Indexed: 01/31/2023] Open
Abstract
Background Procalcitonin (PCT) has emerged as a valuable marker of sepsis. The potential role of PCT in diagnosis and therapy monitoring of intravascular catheter-related bloodstream infections (CRBSI) in intensive care unit (ICU) is still unclear and was evaluated. Methods Forty-six patients were included in the study, provided they were free of infection upon admission and presented the first episode of suspected CRBSI during their ICU stay. Patients who had developed any other infection were excluded. PCT was measured daily during the ICU hospitalization. Primary endpoint was proven CRBSI. Therapy monitoring as according to infection control was also evaluated. Results Among the 46 patients, 26 were diagnosed with CRBSI. Median PCT on the day of infection suspicion (D0) was 7.70 and 0.10 ng/ml for patients with and without proven CRBSI, respectively (p < 0.001). The area under the curve (AUC) for PCT was 0.990 (95% CI; 0.972 – 1.000), whereas a cut-off value of 0.70 ng/ml provided sensitivity and specificity of 92.3 and 100% respectively. In contrast, the AUC for white blood cells (WBC) was 0.539 (95% CI; 0.369 – 0.709), and for C-reactive protein (CRP), 0.603 (95% CI; 0.438 – 0.768). PCT was the best predictor of proven infection. Moreover, an increase >0.20 ng/ml of PCT between the D0 and any of the 4 preceding days was associated with a positive predictive value exceeding 96%. PCT concentrations from the D2 to D6 after suspected infection tended to decrease in controlled patients, whereas remained stable in non-controlled subjects. A PCT concentration exceeding 1.5 ng/ml during D3 was associated with lack of responsiveness to therapy (p = 0.028). Conclusions We suggest that PCT could be a helpful diagnostic and prognostic marker of CRBSI in critically ill patients. Both absolute values and variations should be considered.
Collapse
Affiliation(s)
- Vasiliki P Theodorou
- Department of Intensive Care Unit, University Hospital of Alexandroupolis, Dragana 68100, Alexandroupolis, Greece.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Verkade MA, Epker JL, Nieuwenhoff MD, Bakker J, Kompanje EJO. Withdrawal of life-sustaining treatment in a mixed intensive care unit: most common in patients with catastropic brain injury. Neurocrit Care 2012; 16:130-5. [PMID: 21660623 DOI: 10.1007/s12028-011-9567-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the incidence of withdrawal of life-sustaining treatment in various groups of patients in a mixed intensive care unit (ICU). DESIGN Observational retrospective. SETTING University hospital mixed medical, neurological, neurosurgical and surgical ICU. PATIENTS All patients admitted to the ICU between 1 November 2006, and 31 October 2007. RESULTS 1,353 Patients were admitted to our ICU between 1 November 2006, and 31 October 2007. During this period, 218 (16.1%) patients died in the ICU, 10 of which were excluded for further analysis. In 174 (83.7%) of the remaining 208 patients, life-sustaining treatment was withdrawn. Severe CNS injury was in 86 patients (49.4%) being the reason for withdrawal of treatment, followed by MODS in 67 patients (38.5%). Notably, treatment was withdrawn in almost all patients (95%) who died of CNS failure. Patients who died in the ICU were significantly older, more often admitted for medical than surgical reasons, and had higher SOFA and APACHE II scores compared with those who survived their ICU stay. Also, SOFA scores before discharge/death were significantly different from admission scores. Of the 1,135 patients who survived their ICU stay, only 51 patients (4.5%) died within 28 days after ICU discharge. CONCLUSIONS In 83, 7% of patients who die in the mixed ICU life-sustaining treatment is withdrawn. Severe cerebral damage was the leading reason to withdraw life-sustaining treatment.
Collapse
Affiliation(s)
- Martijn A Verkade
- Department of Intensive Care Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | | | | |
Collapse
|
23
|
Staff satisfaction between 2 models of care for the chronically critically ill. J Crit Care 2012; 27:426.e1-8. [PMID: 22421003 DOI: 10.1016/j.jcrc.2011.12.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 12/30/2011] [Accepted: 12/31/2011] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Chronically critically ill (CCI) patients are a growing population in intensive care units (ICUs), and evidence suggests that this patient group is perceived as demanding by healthcare professionals. However, information is scarce regarding organizational factors that affect staff satisfaction during the care of CCI patients. PURPOSE The purpose of this study was to evaluate staff satisfaction between 2 models of care for the CCI. In the first model, a patient-centered program of care in a traditional ICU was evaluated. In the second model, care of patients hospitalized in a multidisciplinary ICU ward dedicated to the CCI was further evaluated. Indicators of staff satisfaction with respect to the care of the CCI were also identified. METHODS A before and after study was used to evaluate the 2 models of care. After implementation of the first model in 2006, an initial evaluation was performed using a questionnaire given to ICU health-care personnel. In 2009, after implementing the second model (a separate ward for the CCI), a second evaluation took place. RESULTS A total of 147 participants answered the questionnaire in both phases. Participants described CCI as a burden, and grouping these patients into 1 ward only increased this perception. Overall, the staff was more satisfied with the first model of care. In this model, the indicators of increased satisfaction were perceived access to professional development and the availability of information. CONCLUSIONS Results from this study provide information about health-care professionals' perceived burden of care when treating CCI patients. Strategies promoting professional development have a potential to increase staff satisfaction when it comes to the care of this patient group.
Collapse
|
24
|
Abstract
OBJECTIVE To describe the characteristics and risk factors of pediatric patients who receive prolonged mechanical ventilation, defined as ventilatory support for >21 days. DESIGN Prospective cohort. SETTING Four medical-surgical pediatric intensive care units in four university-affiliated hospitals in Argentina. PATIENTS All consecutive patients from 1 month to 15 yrs old admitted to participating pediatric intensive care units from June 1, 2007, to August 31, 2007, who received mechanical ventilation (invasive or noninvasive) for >12 hrs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic and physiologic data on admission to the pediatric intensive care units, drugs and events during the study period, and outcomes were prospectively recorded. A total of 256 patients were included. Of these, 23 (9%) required mechanical ventilation for >21 days and were assigned to the prolonged mechanical ventilation group. Patients requiring prolonged mechanical ventilation had higher mortality (43% vs. 21%, p < .05) and longer pediatric intensive care unit stay: 35 days [28-64 days] vs. 10 days [6-14]). There was no difference between the groups in age and gender distribution, reasons for admission, incidence of immunodeficiencies, or Paediatric Index of Mortality 2 score. The only difference at admission was a higher rate of genetic diseases in prolonged mechanical ventilation patients (26% vs. 9%, p < .05). There was a higher incidence of septic shock (87% vs. 34%, p < .01), acute respiratory distress syndrome (43% vs. 20%, p < .01), and ventilator-associated pneumonia (35% vs. 8%, p < .01) and higher utilization of dopamine (78% vs. 42%, p < .01), norepinephrine (61% vs. 15%, p < .01), multiple antibiotics (83% vs. 20%, p < .01), and blood transfusions (52% vs. 14%, p < .01). The proportion of extubation failure was higher in the prolonged mechanical ventilation group with similar rates of unplanned extubations in both groups. Variables remaining significantly associated with prolonged mechanical ventilation after multivariate analysis were treatment with multiple antibiotics, septic shock, ventilator-associated pneumonia, and use of norepinephrine. CONCLUSIONS Patients with prolonged mechanical ventilation have more complications and require more pediatric intensive care unit resources. Mortality in these patients duplicates that from those requiring shorter support.
Collapse
|
25
|
Hickman RL, Daly BJ, Douglas SL, Burant CJ. Evaluating the critical care family satisfaction survey for chronic critical illness. West J Nurs Res 2011; 34:377-95. [PMID: 21427449 DOI: 10.1177/0193945911402522] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recognition of the family as a component of patient-centered critical care has shifted our attention to the assessment of family satisfaction in the intensive care unit (ICU). To date, there are no established measures of satisfaction with ICU care for family members of the chronically critically ill (CCI). This study evaluated psychometric properties of the Critical Care Family Satisfaction Survey (CCFSS) in 326 family members of the CCI using exploratory and confirmatory factor analysis (CFA). From the exploratory factor analysis, two unique structural models emerged, each with alpha coefficients of .72 to .91 and discriminant validity among factors (r < .70). The CFA confirmed the best-fitting structural model was a 14-item, three-factor solution (χ(2) = 354, df = 148, p < .001, Tucker Lewis Index = .88, Comparative Fit Index = .90, root mean square error of approximation = .06). Thus, the modified 14-item version of the CCFSS is reliable and valid in family members of CCI patients.
Collapse
|
26
|
Abstract
Up to 20% of patients requiring mechanical ventilation will suffer from difficult weaning (the need of more than 7 days of weaning after the first spontaneous breathing trial), which may depend on several reversible causes: respiratory and/or cardiac load, neuromuscular and neuropsychological factors, and metabolic and endocrine disorders. Clinical consequences (and/or often causes) of prolonged mechanical ventilation comprise features such as myopathy, neuropathy, and body composition alterations and depression, which increase the costs, morbidity and mortality of this. These difficult-to-wean patients may be managed in two type of units: respiratory intermediate-care units and specialized regional weaning centers. Two weaning protocols are normally used: progressive reduction of ventilator support (which we usually use), or progressively longer periods of spontaneous breathing trials. Physiotherapy is an important component of weaning protocols. Weaning success depends strongly on patients’ complexity and comorbidities, hospital organization and personnel expertise, availability of early physiotherapy, use of weaning protocols, patients’ autonomy and families’ preparation for home discharge with mechanical ventilation.
Collapse
Affiliation(s)
- Nicolino Ambrosino
- Cardiothoracic Department, Pulmonary Unit, University Hospital of Pisa, Via Paradisa 2, Cisanello, Pisa, Italy.
| | | |
Collapse
|
27
|
|
28
|
Boniatti MM, Friedman G, Castilho RK, Vieira SRR, Fialkow L. Characteristics of chronically critically ill patients: comparing two definitions. Clinics (Sao Paulo) 2011; 66:701-4. [PMID: 21655767 PMCID: PMC3093802 DOI: 10.1590/s1807-59322011000400027] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
|
29
|
Martin B, Koesel N. Nurses' role in clarifying goals in the intensive care unit. Crit Care Nurse 2010; 30:64-73. [PMID: 20515884 DOI: 10.4037/ccn2010511] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Beth Martin
- Hospice and Palliative Care Charlotte Region, E 7th Street, Charlotte, NC 28204, USA.
| | | |
Collapse
|
30
|
Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical illness. Am J Respir Crit Care Med 2010; 182:446-54. [PMID: 20448093 DOI: 10.1164/rccm.201002-0210ci] [Citation(s) in RCA: 388] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Although advances in intensive care have enabled more patients to survive an acute critical illness, they also have created a large and growing population of chronically critically ill patients with prolonged dependence on mechanical ventilation and other intensive care therapies. Chronic critical illness is a devastating condition: mortality exceeds that for most malignancies, and functional dependence persists for most survivors. Costs of treating the chronically critically ill in the United States already exceed $20 billion and are increasing. In this article, we describe the constellation of clinical features that characterize chronic critical illness. We discuss the outcomes of this condition including ventilator liberation, mortality, and physical and cognitive function, noting that comparisons among cohorts are complicated by variation in defining criteria and care settings. We also address burdens for families of the chronically critically ill and the difficulties they face in decision-making about continuation of intensive therapies. Epidemiology and resource utilization issues are reviewed to highlight the impact of chronic critical illness on our health care system. Finally, we summarize the best available evidence for managing chronic critical illness, including ventilator weaning, nutritional support, rehabilitation, and palliative care, and emphasize the importance of efforts to prevent the transition from acute to chronic critical illness. As steps forward for the field, we suggest a specific definition of chronic critical illness, advocate for the creation of a research network encompassing a broad range of venues for care, and highlight areas for future study of the comparative effectiveness of different treatment venues and approaches.
Collapse
Affiliation(s)
- Judith E Nelson
- Department of Medicine, Hertzberg Palliative Care Institute, Mount Sinai School of Medicine, New York, New York 10029, USA.
| | | | | | | |
Collapse
|
31
|
To KKW, Hung IFN, Li IWS, Lee KL, Koo CK, Yan WW, Liu R, Ho KY, Chu KH, Watt CL, Luk WK, Lai KY, Chow FL, Mok T, Buckley T, Chan JFW, Wong SSY, Zheng B, Chen H, Lau CCY, Tse H, Cheng VCC, Chan KH, Yuen KY. Delayed clearance of viral load and marked cytokine activation in severe cases of pandemic H1N1 2009 influenza virus infection. Clin Infect Dis 2010; 50:850-9. [PMID: 20136415 PMCID: PMC7107930 DOI: 10.1086/650581] [Citation(s) in RCA: 334] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Infections caused by the pandemic H1N1 2009 influenza virus range from mild upper respiratory tract syndromes to fatal diseases. However, studies comparing virological and immunological profile of different clinical severity are lacking. METHODS We conducted a retrospective cohort study of 74 patients with pandemic H1N1 infection, including 23 patients who either developed acute respiratory distress syndrome (ARDS) or died (ARDS-death group), 14 patients with desaturation requiring oxygen supplementation and who survived without ARDS (survived-without-ARDS group), and 37 patients with mild disease without desaturation (mild-disease group). We compared their pattern of clinical disease, viral load, and immunological profile. RESULTS Patients with severe disease were older, more likely to be obese or having underlying diseases, and had lower respiratory tract symptoms, especially dyspnea at presentation. The ARDS-death group had a slower decline in nasopharyngeal viral loads, had higher plasma levels of proinflammatory cytokines and chemokines, and were more likely to have bacterial coinfections (30.4%), myocarditis (21.7%), or viremia (13.0%) than patients in the survived-without-ARDS or the mild-disease groups. Reactive hemophagocytosis, thrombotic phenomena, lymphoid atrophy, diffuse alveolar damage, and multiorgan dysfunction similar to fatal avian influenza A H5N1 infection were found at postmortem examinations. CONCLUSIONS The slower control of viral load and immunodysregulation in severe cases mandate the search for more effective antiviral and immunomodulatory regimens to stop the excessive cytokine activation resulting in ARDS and death.
Collapse
Affiliation(s)
- Kelvin K W To
- Infectious Disease Division, Queen Mary Hospital, State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, The University of Hong Kong, Hong Kong, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Hickman RL, Douglas SL. Impact of chronic critical illness on the psychological outcomes of family members. AACN Adv Crit Care 2010; 21:80-91. [PMID: 20118707 PMCID: PMC3037826 DOI: 10.1097/nci.0b013e3181c930a3] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The uncertain trajectory of chronic critical illness exposes the patient's family to heightened levels of psychological distress. Symptoms of psychological distress affect more than half of family members exposed to the patient's chronic critical illness. Although symptoms often dissipate over time, a significant proportion of family members will remain at moderate to high risk for psychological distress well after the patient's death or discharge from the intensive care unit. Family members of chronically critically ill patients are often involved in the decision making for the patients. Irrational or uninformed decision making can occur when family members experience high levels of psychological distress. Attention to the psychological needs and provision of support to family members enhance the formulation of treatment decisions consistent with the patient's preferences and mitigate unnecessary resource use. In this article, the impact of chronic critical illness on family members' risk for depression, anxiety, and posttraumatic stress disorder is described and a review of evidence-based strategies to support the psychological needs of family members coping with a patient's chronic critical illness is provided.
Collapse
Affiliation(s)
- Ronald L Hickman
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106, USA.
| | | |
Collapse
|
33
|
Tsangaris I, Plachouras D, Kavatha D, Gourgoulis GM, Tsantes A, Kopterides P, Tsaknis G, Dimopoulou I, Orfanos S, Giamarellos-Bourboulis E, Giamarellou H, Armaganidis A. Diagnostic and prognostic value of procalcitonin among febrile critically ill patients with prolonged ICU stay. BMC Infect Dis 2009; 9:213. [PMID: 20028533 PMCID: PMC2803794 DOI: 10.1186/1471-2334-9-213] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2009] [Accepted: 12/22/2009] [Indexed: 02/08/2023] Open
Abstract
Background Procalcitonin (PCT) has been proposed as a diagnostic and prognostic sepsis marker, but has never been validated in febrile patients with prolonged ICU stay. Methods Patients were included in the study provided they were hospitalised in the ICU for > 10 days, were free of infection and presented a new episode of SIRS, with fever >38°C being obligatory. Fifty patients fulfilled the above criteria. PCT was measured daily during the ICU stay. The primary outcome was proven infection. Results Twenty-seven out of 50 patients were diagnosed with infection. Median PCT on the day of fever was 1.18 and 0.17 ng/ml for patients with and without proven infections (p < 0.001). The area under the curve for PCT was 0.85 (95% CI; 0.71-0.93), for CRP 0.65 (0.46-0.78) and for WBC 0.68 (0.49-0.81). A PCT level of 1 ng/mL yielded a negative predictive value of 72% for the presence of infection, while a PCT of 1.16 had a specificity of 100%. A two-fold increase of PCT between fever onset and the previous day was associated with proven infection (p 0.001) (OR = 8.55; 2.4-31.1), whereas a four-fold increase of PCT of any of the 6 preceding days was associated with a positive predictive value exceeding 69.65%. A PCT value less than 0.5 ng/ml on the third day after the advent of fever was associated with favorable survival (p 0.01). Conclusion The reported data support that serial serum PCT may be a valuable diagnostic and prognostic marker in febrile chronic critically ill patients.
Collapse
Affiliation(s)
- Iraklis Tsangaris
- The 2nd Critical Care Department, Attikon University General Hospital, Medical School, University of Athens, 1 Rimini Str,, 12462, Athens, Greece.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Lee K, Hong SB, Lim CM, Koh Y. Sequential organ failure assessment score and comorbidity: valuable prognostic indicators in chronically critically ill patients. Anaesth Intensive Care 2008; 36:528-34. [PMID: 18714621 DOI: 10.1177/0310057x0803600422] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Chronically critically ill patients are defined as those who survive initial life-threatening, possibly reversible organ failure(s) but are unable to recover rapidly to a point at which they are fully independent of life support. Accordingly, these patients require mechanical ventilation and medical resources for a long time in an intensive care unit (ICU). The present study analysed demographic, clinical and survival data of chronically critically ill patients, to identify condition(s) related to poor prognosis. A total of 141 chronically critically ill patients were studied retrospectively over a two-year period (July 1, 2003 to June 30, 2005). Their mean lengths of stay in the ICU and in the hospital were 42.9+/-36.4 and 83.9+/-100.5 days respectively. ICU and six-month cumulative mortality rates were 42.6% and 75.9% respectively. Non-survivors had a significantly higher Sequential Organ Failure Assessment (SOFA) score than survivors on day 21 of ICU admission, as well as having significantly lower changes of SOFA scores between days three and 21. Multivariate analysis demonstrated that the SOFA score on day 21 and the Charlson Comorbidity Index were the best predictor of survival for six months after hospital discharge. The SOFA score on day 21 and comorbidity in the ICU appears to be a valuable prognostic indicators in chronically critically ill patients.
Collapse
Affiliation(s)
- K Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center University of Ulsan College of Medicine, Seoul, Korea
| | | | | | | |
Collapse
|
35
|
Bahadur K, Jones G, Ntoumenopoulos G. An observational study of sitting out of bed in tracheostomised patients in the intensive care unit. Physiotherapy 2008. [DOI: 10.1016/j.physio.2008.08.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
36
|
Veelo DP, Gajic O, Schultz MJ. Benefits of early tracheotomy: underpowered or overestimated? Intensive Care Med 2008; 34:2309; author reply 2310-1. [PMID: 18853136 DOI: 10.1007/s00134-008-1329-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2008] [Indexed: 10/21/2022]
|
37
|
Soares M, Salluh JI, Torres VB, Leal JV, Spector N. Short- and Long-term Outcomes of Critically Ill Patients With Cancer and Prolonged ICU Length of Stay. Chest 2008; 134:520-526. [DOI: 10.1378/chest.08-0359] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
|
38
|
|
39
|
|
40
|
Nelson JE, Mercado AF, Camhi SL, Tandon N, Wallenstein S, August GI, Morrison RS. Communication about chronic critical illness. ACTA ACUST UNITED AC 2008; 167:2509-15. [PMID: 18071175 DOI: 10.1001/archinte.167.22.2509] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Despite poor outcomes, life-sustaining treatments including mechanical ventilation are continued for a large and growing population of patients with chronic critical illness. This may be owing in part to a lack of understanding resulting from inadequate communication between clinicians and patients and families. Our objective was to investigate the informational needs of patients with chronic critical illness and their families and the extent to which these needs are met. METHODS In this prospective observational study conducted at 5 adult intensive care units in a large, university-affiliated hospital in New York, New York, 100 patients with chronic critical illness (within 3-7 days of elective tracheotomy for prolonged mechanical ventilation) or surrogates for incapacitated patients were surveyed using an 18-item questionnaire addressing communication about chronic critical illness. Main outcome measures included ratings of importance and reports of whether information was received about questionnaire items. RESULTS Among 125 consecutive, eligible patients, 100 (80%) were enrolled; questionnaire respondents included 2 patients and 98 surrogates. For all items, more than 78% of respondents rated the information as important for decision making (>98% for 16 of 18 items). Respondents reported receiving no information for a mean (SD) of 9.0 (3.3) of 18 items, with 95% of respondents reporting not receiving information for approximately one-quarter of the items. Of the subjects rating the item as important, 77 of 96 (80%) and 69 of 74 (93%) reported receiving no information about expected functional status at hospital discharge and prognosis for 1-year survival, respectively. CONCLUSIONS Many patients and their families may lack important information for decision making about continuation of treatment in the chronic phase of critical illness. Strategies for effective communication in this clinical context should be investigated and implemented.
Collapse
|
41
|
Schultz MJ, Kuiper M, Spronk PE, Vroom MB, Gajic O. Year in review 2006: Critical Care--Resource management. Crit Care 2007; 11:223. [PMID: 17764592 PMCID: PMC2206496 DOI: 10.1186/cc5961] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
As health care resources become increasingly constrained, it is imperative that intensive care unit resources be optimized. In the years to come, a number of challenges to intensive care medicine will need to be addressed as society changes. Last year's Critical Care papers provided us with a number of interesting and highly accessed original papers dealing with health care resources. The information yielded by these studies can help us to deal with issues such as prognostication, early detection and treatment of delirium, prevention of medical errors and use of radiology resources in critically ill patients. Finally, several aspects of scientific research in critically ill patients were investigated, focusing on the possibility of obtaining informed consent and recall of having given informed consent.
Collapse
Affiliation(s)
- Marcus J Schultz
- Department of Intensive Care Medicine, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- HERMES Critical Care Group, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Michael Kuiper
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Intensive Care Medicine, Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Peter E Spronk
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Intensive Care Medicine, Gelre Hospital, location Lukas, Albert Schweitzerlaan 31, 7334 DZ Apeldoorn, The Netherlands
| | - Margreeth B Vroom
- Department of Intensive Care Medicine, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ognjen Gajic
- Department of Intensive Care Medicine, Mayo Clinic, First Street 200 SW, Rochester, MN 55905, USA
| |
Collapse
|