ICU-Acquired Weakness

Ultramicronized Palmitoylethanolamide and Luteolin: Drug Candidates in Post-COVID-19 Critical Illness Neuropathy and Positioning-Related Peripheral Nerve Injury of the Upper Extremity

Coronavirus disease 2019 (COVID-19) is the most dramatic pandemic of the new millennium and patients with serious infection can stay in intensive care unit (ICU) for weeks in a clinical scenario of systemic inflammatory response syndrome, likely related to the subsequent development of critical illness polyneuropathy (CIP). It is in fact now accepted that COVID-19 ICU surviving patients can develop CIP; moreover, prone positioning-related stretch may favor the onset of positioning-related peripheral nerve injuries (PNI). Therefore, the urgent need to test drug candidates for the treatment of these debilitating sequelae is emerged even more. For the first time in medical literature, we have successfully treated after informed consent a 71-year-old Italian man suffering from post-COVID-19 CIP burdened with positioning-related PNI of the left upper extremity by means of ultramicronized palmitoylethanolamide 400 mg plus ultramicronized luteolin 40 mg (Glìalia), two tablets a day 12 hours apart for 6 months. In the wake of our pilot study, a larger clinical trial to definitively ascertain the advantages of this neuroprotective, neurotrophic, and anti-inflammatory therapy is advocated.

THE EFFECT OF IN-BED LEG CYCLING EXERCISES ON MUSCLE STRENGTH IN PATIENTS WITH INTENSIVE CARE UNIT-ACQUIRED WEAKNESS: A SINGLE-CENTER RETROSPECTIVE STUDY

Objective

To examine the effect of in-bed leg cycling exercise on patients with intensive care unit-acquired weakness (ICU-AW).

Design

Single-center retrospective study.

Subjects/Patients

Patients admitted to the ICU between January 2019 and March 2023 were enrolled in the ergometer group, and those admitted to the ICU between August 2017 and December 2018 were enrolled in the control group.

Methods

The ergometer group performed in-bed leg cycling exercises 5 times per week for 20 min from the day of ICU-AW diagnosis. Furthermore, the ergometer group received 1 early mobilization session per day according to the early mobilization protocol, whereas the control group received 1 or 2 sessions per day. The number of patients with recovery from ICU-AW at ICU discharge and improvement in physical functions were compared.

Results

Significantly more patients in the ergometer group recovered from ICU-AW than in the control group (87.0% vs 60.6%, p = 0.039). Regarding physical function, the ergometer group showed significantly higher improvement efficiency in Medical Research Council sum score (1.0 [0.7-2.1] vs 0.1 [0.0-0.2], p < 0.001).

Conclusion

In-bed leg cycling exercise, in addition to the early mobilization protocol, reduced the number of patients with ICU-AW at ICU discharge.

Neuromuscular Disorders Associated With COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has had an enormous impact on practically every aspect of daily life, and those with neuromuscular disorders have certainly not been spared. The effects of COVID-19 infection are far-reaching, going well beyond respiratory symptoms alone. From simple myalgias to debilitating critical illness neuromyopathies, we continue to learn and catalog the diverse pathologies presented by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as it relates to the neuromuscular system. Complications have been documented both as a direct result of primary infection but also in those with pre-existing neuromuscular disorders from myasthenia gravis to devastating critical illness neuromyopathies. In this review, we will discuss the relationship between COVID-19 infection and critical illness neuromyopathy, peripheral nerve palsies, myalgias, positional compressive neuropathy, myasthenia gravis, and Guillain-Barré syndrome.

Association between neuromuscular blocking agents and the development of intensive care unit-acquired weakness (ICU-AW): A systematic review with meta-analysis and trial sequential analysis

BACKGROUND

The present study aims to review the literature and synthesize evidence concerning the effects of the use of neuromuscular blocking agents (NMBA) regarding the development of intensive care unit-acquired weakness (ICU-AW).

METHODS

This study was registered in the PROSPERO database CRD42020142916. Systematic review in PubMed, Embase, and the Cochrane Central, Randomized clinical trials (RCTs), and cohort studies with adults that reported the use of NMBA and the development of ICU-AW were included. Pre-specified subgroup analyses were performed for presence of sepsis and type of NMBA used. The quality of evidence for intervention effects was summarized. The certainty of evidence was assessed using the GRADE approach.

RESULTS

We included 30 studies, four RCTs, 21 prospective and 5 retrospective cohorts, enrolling a total of 3839 patients. Most of the included studies were observational with high heterogeneity, whereas the RCTs had a high risk of bias. The use of NMBA increased the odds of developing ICU-AW (OR = 2.77 [95% CI 1.98-3.88], I² = 62%), with low-quality of evidence. A trial sequential analysis showed the need to include 22,330 patients in order to provide evidence for either beneficial or harmful intervention effects.

CONCLUSIONS

This meta-analysis suggests that the use of NMBA might be implicated in the development of ICU-AW. However, there is not enough evidence to definitively conclude about the association between the use of NMBA and the development of ICU-AW, as these results are based mostly on observational studies with high heterogeneity.

Perioperative Optimization of the Cardiac Surgical Patient

Perioperative optimization of cardiac surgical patients is imperative to reduce complications, utilize health care resources efficiently, and improve patient recovery and quality of life. Standardized application of evidence-based best practices can lead to better outcomes. Although many practices should be applied universally to all patients, there are also opportunities along the surgical journey to identify patients who will benefit from additional interventions that will further ameliorate their recovery. Enhanced recovery programs aim to bundle several process elements in a standardized fashion to optimize outcomes after cardiac surgery. A foundational concept of enhanced recovery is attaining a better postsurgical end point for patients, in less time, through achievement and maintenance in their greatest possible physiologic, functional, and psychological state. Perioperative optimization is a broad topic, spanning multiple phases of care and involving a variety of medical specialties and nonphysician health care providers. In this review we highlight a variety of perioperative care topics, in which a comprehensive approach to patient care can lead to improved results for patients, providers, and the health care system. A particular focus on patient-centred care is included. Although existing evidence supports all of the elements reviewed, most require further improvements in implementation, as well as additional research, before their full potential and usefulness can be determined.

Hospital Strain and Variation in Sepsis ICU Admission Practices and Associated Outcomes

To understand how strain-process-outcome relationships in patients with sepsis may vary among hospitals.

DESIGN

Retrospective cohort study using a validated hospital capacity strain index as a within-hospital instrumental variable governing ICU versus ward admission, stratified by hospital.

SETTING

Twenty-seven U.S. hospitals from 2013 to 2018.

PATIENTS

High-acuity emergency department patients with sepsis who do not require life support therapies.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The mean predicted probability of ICU admission across strain deciles ranged from 4.9% (lowest ICU-utilizing hospital for sepsis without life support) to 61.2% (highest ICU-utilizing hospital for sepsis without life support). The difference in the predicted probabilities of ICU admission between the lowest and highest strain deciles ranged from 9.0% (least strain-sensitive hospital) to 45.2% (most strain-sensitive hospital). In pooled analyses, emergency department patients with sepsis (n = 90,150) experienced a 1.3-day longer median hospital length of stay (LOS) if admitted initially to the ICU compared with the ward, but across the 27 study hospitals (n = 517-6,564), this effect varied from 9.0 days shorter (95% CI, -10.8 to -7.2; p < 0.001) to 19.0 days longer (95% CI, 16.7-21.3; p < 0.001). Corresponding ranges for inhospital mortality with ICU compared with ward admission revealed odds ratios (ORs) from 0.16 (95% CI, 0.03-0.99; p = 0.04) to 4.62 (95% CI, 1.16-18.22; p = 0.02) among patients with sepsis (pooled OR = 1.48).

CONCLUSIONS

There is significant among-hospital variation in ICU admission rates for patients with sepsis not requiring life support therapies, how sensitive those ICU admission decisions are to hospital capacity strain, and the association of ICU admission with hospital LOS and hospital mortality. Hospital-level heterogeneity should be considered alongside patient-level heterogeneity in critical and acute care study design and interpretation.

Patient-centered outcomes at hospital discharge in mechanically ventilated COVID-19 patients in Kobe, Japan: A single-center retrospective cohort study

BACKGROUND

Apart from saving the lives of coronavirus disease (COVID-19) patients on mechanical ventilation (MV), recovery from the sequelae of prolonged MV (PMV) is an emerging issue.c METHODS: We conducted a retrospective study among consecutive adult COVID-19 patients admitted to an intensive care unit (ICU) in Kobe, Japan, between March 3, 2020, and January 31, 2021, and received invasive MV. Clinical outcomes included in-hospital mortality and recovery from COVID-19 in survivors regarding organ dysfunction, respiratory symptoms, and functional status at discharge. We compared survivors' outcomes with MV durations of >14 days and ≤14 days.

RESULTS

We included 85 patients with a median age of 69 years (interquartile range, 64-75 years); 76 (89%) patients had at least 1 comorbidity, 72 (85%) were non-frail, and 79 (93%) were functionally independent before COVID-19 infection. Eighteen patients (21%) died during hospitalization. At discharge, 59/67 survivors (88%) no longer required respiratory support, 50 (75%) complained of dyspnea, and 40 (60%) were functionally independent. Of the survivors, 23 patients receiving MV for >14 days had a worse recovery from COVID-19 at discharge compared with those on MV for ≤14 days, as observed using the Barthel index (median: 35 [5-65] vs. 100 [85-100]), ICU mobility scale (8 [5-9] vs. 10 [10-10]), and functional oral intake scale (3 [1-7] vs. 7 [7-7]) (P < 0.0001).

CONCLUSION

Although four-fifths of the patients survived and >50% of survivors demonstrated clinically important recovery in organ function and functional status during hospitalization, PMV was related to poor recovery from COVID-19 at discharge.

Too much tolerance for hyperoxemia in mechanically ventilated patients with SARS-CoV-2 pneumonia? Report from an Italian intensive care unit

Background

In COVID-19 patients requiring mechanical ventilation, the administration of high oxygen (O2) doses for prolonged time periods may be necessary. Although life-saving in most cases, O2 may exert deleterious effects if administered in excessive concentrations. We aimed to describe the prevalence of hyperoxemia and excessive O2 administration in mechanically ventilated patients with SARS-CoV-2 pneumonia and determine whether hyperoxemia is associated with mortality in the Intensive Care Unit (ICU) or the onset of ventilator-associated pneumonia (VAP).

Materials and methods

Retrospective single-center study on adult patients with SARS-CoV-2 pneumonia requiring invasive mechanical ventilation for ≥48 h. Patients undergoing extracorporeal respiratory support were excluded. We calculated the excess O2 administered based on the ideal arterial O2 tension (PaO2) target of 55-80 mmHg. We defined hyperoxemia as PaO2 > 100 mmHg and hyperoxia + hyperoxemia as an inspired O2 fraction (FiO2) > 60% + PaO2 > 100 mmHg. Risk factors for ICU-mortality and VAP were assessed through multivariate analyses.

Results

One hundred thirty-four patients were included. For each day of mechanical ventilation, each patient received a median excess O2 of 1,121 [829-1,449] L. Hyperoxemia was found in 38 [27-55]% of arterial blood gases, hyperoxia + hyperoxemia in 11 [5-18]% of cases. The FiO2 was not reduced in 69 [62-76]% of cases of hyperoxemia. Adjustments were made more frequently with higher PaO2 or initial FiO2 levels. ICU-mortality was 32%. VAP was diagnosed in 48.5% of patients. Hyperoxemia (OR 1.300 95% CI [1.097-1.542]), time of exposure to hyperoxemia (OR 2.758 [1.406-5.411]), hyperoxia + hyperoxemia (OR 1.144 [1.008-1.298]), and daily excess O2 (OR 1.003 [1.001-1.005]) were associated with higher risk for ICU-mortality, independently of age, Sequential Organ failure Assessment score at ICU-admission and mean PaO2/FiO2. Hyperoxemia (OR 1.033 [1.006-1.061]), time of exposure to hyperoxemia (OR 1.108 [1.018-1.206]), hyperoxia + hyperoxemia (OR 1.038 [1.003-1.075]), and daily excess O2 (OR 1.001 [1.000-1.001]) were identified as risk factors for VAP, independently of body mass index, blood transfusions, days of neuromuscular blocking agents (before VAP), prolonged prone positioning and mean PaO2/FiO2 before VAP.

Conclusion

Excess O2 administration and hyperoxemia were common in mechanically ventilated patients with SARS-CoV-2 pneumonia. The exposure to hyperoxemia may be associated with ICU-mortality and greater risk for VAP.

Awake extracorporeal life support and physiotherapy in adult patients: A systematic review of the literature

OBJECTIVE

The Awake Extracorporeal Life Support (ECLS) practice combined with physiotherapy is increasing. However, available evidence for this approach is limited, with unclear indications on timing, management, and protocols. This review summarizes available literature regarding Awake ECLS and physiotherapy application rates, practices, and outcomes in adults, providing indications for future investigations.

METHODS

Four databases were screened from inception to February 2021, for studies reporting adult Awake ECLS with/without physiotherapy. Primary outcome was hospital discharge survival, followed by Extracorporeal Membrane Oxygenation (ECMO) duration, extubation, Intensive Care Unit stay.

RESULTS

Twenty-nine observational studies and one randomized study were selected, including 1,157 patients (males n = 611/691, 88.4%) undergoing Awake ECLS. Support type was reported in 1,089 patients: Veno-Arterial ECMO (V-A = 39.6%), Veno-Venous ECMO (V-V = 56.8%), other ECLS (3.6%). Exclusive upper body cannulation and femoral cannulation were applied in 31% versus 69% reported cases (n = 931). Extubation was successful in 63.5% (n = 522/822) patients during ECLS. Physiotherapy details were given for 676 patients: exercises confined in bed for 47.9% (n = 324) patients, mobilization until standing in 9.3% (n = 63) cases, ambulation performed in 42.7% (n = 289) patients. Femoral cannulation, extubation and V-A ECMO were mostly correlated to complications. Hospital discharge survival observed in 70.8% (n = 789/1114).

CONCLUSION

Awake ECLS strategy associated with physiotherapy is performed regardless of cannulation approach. Ambulation, as main objective, is achieved in almost half the population examined. Prospective studies are needed to evaluate safety and efficacy of physiotherapy during Awake ECLS, and suitable patient selection. Guidelines are required to identify appropriate assessment/evaluation tools for Awake ECLS patients monitoring.

Hidden Agenda - The Involvement of Endoplasmic Reticulum Stress and Unfolded Protein Response in Inflammation-Induced Muscle Wasting

Critically ill patients at the intensive care unit (ICU) often develop a generalized weakness, called ICU-acquired weakness (ICUAW). A major contributor to ICUAW is muscle atrophy, a loss of skeletal muscle mass and function. Skeletal muscle assures almost all of the vital functions of our body. It adapts rapidly in response to physiological as well as pathological stress, such as inactivity, immobilization, and inflammation. In response to a reduced workload or inflammation muscle atrophy develops. Recent work suggests that adaptive or maladaptive processes in the endoplasmic reticulum (ER), also known as sarcoplasmic reticulum, contributes to this process. In muscle cells, the ER is a highly specialized cellular organelle that assures calcium homeostasis and therefore muscle contraction. The ER also assures correct folding of proteins that are secreted or localized to the cell membrane. Protein folding is a highly error prone process and accumulation of misfolded or unfolded proteins can cause ER stress, which is counteracted by the activation of a signaling network known as the unfolded protein response (UPR). Three ER membrane residing molecules, protein kinase R-like endoplasmic reticulum kinase (PERK), inositol requiring protein 1a (IRE1a), and activating transcription factor 6 (ATF6) initiate the UPR. The UPR aims to restore ER homeostasis by reducing overall protein synthesis and increasing gene expression of various ER chaperone proteins. If ER stress persists or cannot be resolved cell death pathways are activated. Although, ER stress-induced UPR pathways are known to be important for regulation of skeletal muscle mass and function as well as for inflammation and immune response its function in ICUAW is still elusive. Given recent advances in the development of ER stress modifying molecules for neurodegenerative diseases and cancer, it is important to know whether or not therapeutic interventions in ER stress pathways have favorable effects and these compounds can be used to prevent or treat ICUAW. In this review, we focus on the role of ER stress-induced UPR in skeletal muscle during critical illness and in response to predisposing risk factors such as immobilization, starvation and inflammation as well as ICUAW treatment to foster research for this devastating clinical problem.

Mucus Clearance Strategies in Mechanically Ventilated Patients

The use of airway clearance strategies as supplementary treatment in respiratory disease has been best investigated in patients with cystic fibrosis (CF) and non-cystic fibrosis bronchiectasis (NCFBE), conditions which are traditionally characterized by excessive mucus stasis and mucociliary dysfunction. A variety of airway clearance therapies both pharmacological and non-pharmacological have been shown to ameliorate disease progression in this population and have hence been assimilated into routine respiratory care. This self-propagating cycle of mucus retention and airway damage leading to chronic inflammation and infections can also be applied to patients with respiratory failure requiring mechanical ventilation. Furthermore, excessive trachea-bronchial secretions have been associated with extubation failure presenting an opportunity for intervention. Evidence for the use of adjunctive mucoactive agents and other therapies to facilitate secretion clearance in these patients are not well defined, and this subgroup still remains largely underrepresented in clinical trials. In this review, we discuss the role of mucus clearance techniques with a proven benefit in patients with CF and NCFBE, and their potential role in patients requiring mechanical ventilation while highlighting the need for standardization and adoption of mucus clearance strategies in these patient populations.

Nutrition during extracorporeal life support: A review of pathophysiological bases and application of guidelines

BACKGROUND

Patients on extracorporeal life support (ECLS), either for respiratory or cardiac support, are at high risk of malnutrition; guidelines on nutrition in critical care have not incorporated solid evidence regarding these settings. The aim of this narrative review is to gather the available evidence in the existing literature and transpose general principles to the ECLS population.

METHODS

A literature review of observational and interventional studies on nutrition during ECLS, and evaluation of nutrition guidelines in this perspective.

RESULTS

Nutrition is paramount for improving outcomes in ECLS, as well as in critically ill patients. The caloric needs during ECLS can vary according to the severity of the clinical state, sedation, paralysis, and temperature stability. Precise evaluation of energy expenditure by indirect calorimetry is difficult because ECLS is a system dedicated to removing carbon dioxide; however, modified equations composed of carbon dioxide values taken from the membrane lung are available. Guidelines suggest starting early enteral nutrition (EN) with a hypocaloric (70%-80% of the needs) strategy, also in acute states such as septic or cardiogenic shock. Moreover, EN, despite previous concerns, is feasible in prone position, an increasingly adopted strategy during mechanical ventilation. The catabolic state is maximal in these patients, causing a protein and muscular reduction. Therefore, adequate protein delivery should be guaranteed by administering a high protein intake of up to 2 g/kg/day.

CONCLUSIONS

Studies on nutrition tailored to ECLS patients are warranted. Early hypocaloric EN with high protein intake, tailored on indirect calorimetry, may be the most appropriate option.

Post-Intensive Care Syndrome in Survivors from Critical Illness including COVID-19 Patients: A Narrative Review

Current achievements in medical science and technological advancements in intensive care medicine have allowed better support of critically ill patients in intensive care units (ICUs) and have increased survival probability. Post-intensive care syndrome (PICS) is a relatively new term introduced almost 10 years ago, defined as "new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization". A significant percentage of critically ill patients suffer from PICS for a prolonged period of time, with physical problems being the most common. The exact prevalence of PICS is unknown, and many risk factors have been described well. Coronavirus disease 2019 (COVID-19) survivors seem to be at especially high risk for developing PICS. The families of ICU survivors can also be affected as a response to the stress suffered during the critical illness of their kin. This separate entity is described as PICS family (PICS-F). A multidisciplinary approach is warranted for the treatment of PICS, involving healthcare professionals, clinicians, and scientists from different areas. Improving outcomes is both challenging and imperative for the critical care community. The review of the relevant literature and the study of the physical, cognitive, and mental sequelae could lead to the prevention and timely management of PICS and the subsequent improvement of the quality of life for ICU survivors.

Impact of mechanical ventilation time on functional capacity and muscular strength of patients under intensive care

Abstract Introduction: A prolonged assisted ventilation (AV) period might induce complications. Objective: To compare functional capacities and muscle strength of patients under AV. Methods: This is a prospective cohort observational study. The patients selected were under mechanical ventilation in any given moment, and they were evaluated only at the time of discharge from the intensive care unit (ICU). The convenience sample of 103 was selected and divided into a group with up to six days of AV (G6) and another with seven days or more of AV (G7). The protocol proposed was: application of the Medical Research Council (MRC) scale, dynamometry, Barthel index, ability to ambulate at ICU discharge. A call was made to the patients six and 12 months after hospital discharge for the application of the Barthel index. Results: We verified that G6 patients obtained better muscular strength measured through right 14 (8-30) and left 18 (8-26) dynamometry and MRC scale 48 (44-56). Only seven (14%) patients from the G7 group were able to ambulate. G7 patients showed greater functional loss at hospital discharge 32 (15-60). After one year of hospital discharge, both groups had recovered their functional capacity 100 (100-100). Conclusion: When evaluating the process of AV, it is possible to conclude that the longer the ventilator is used, the greater the loss of strength and functionality. In addition, there is a significant recovery of functionality after one year of hospital discharge.

The effect of passive mobilization associated with blood flow restriction and combined with electrical stimulation on cardiorespiratory safety, neuromuscular adaptations, physical function, and quality of life in comatose patients in an ICU: a randomized controlled clinical trial

Background

Intensive care unit-acquired atrophy and weakness are associated with high mortality, a reduction in physical function, and quality of life. Passive mobilization (PM) and neuromuscular electrical stimulation were applied in comatose patients; however, evidence is inconclusive regarding atrophy and weakness prevention. Blood flow restriction (BFR) associated with PM (BFRp) or with electrical stimulation (BFRpE) was able to reduce atrophy and increase muscle mass in spinal cord-injured patients, respectively. Bulky venous return occurs after releasing BFR, which can cause unknown repercussions on the cardiovascular system. Hence, the aim of this study was to investigate the effect of BFRp and BFRpE on cardiovascular safety and applicability, neuromuscular adaptations, physical function, and quality of life in comatose patients in intensive care units (ICUs).

Methods

Thirty-nine patients will be assessed at baseline (T0–18 h of coma) and randomly assigned to the PM (control group), BFRp, or BFRpE groups. The training protocol will be applied in both legs alternately, twice a day with a 4-h interval until coma awake, death, or ICU discharge. Cardiovascular safety and applicability will be evaluated at the first training session (T1). At T0 and 12 h after the last session (T2), muscle thickness and quality will be assessed. Global muscle strength and physical function will be assessed 12 h after T2 and ICU and hospital discharge for those who wake up from coma. Six and 12 months after hospital discharge, physical function and quality of life will be re-assessed.

Discussion

In view of applicability, the data will be used to inform the design and sample size of a prospective trial to clarify the effect of BFRpE on preventing muscle atrophy and weakness and to exert the greatest beneficial effects on physical function and quality of life compared to BFRp in comatose patients in the ICU.

Trial registration

Universal Trial Number (UTN) Registry UTN U1111-1241-4344. Retrospectively registered on 2 October 2019. Brazilian Clinical Trials Registry (ReBec) RBR-2qpyxf. Retrospectively registered on 21 January 2020, http://ensaiosclinicos.gov.br/rg/RBR-2qpyxf/

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05916-z.

Efficacy of Acupuncture Combined with Rehabilitation Training for Intensive Care Unit-Acquired Muscle Weakness: A Protocol for a Randomized, Sham-Procedure-Controlled Clinical Trial

To evaluate the efficacy of acupuncture combined with rehabilitation training in patients with intensive care unit (ICU)-acquired muscle weakness (ICUAW), a single-blinded, randomized, sham-controlled clinical trial is designed for execution. In total, 56 participants with ICUAW will be randomly assigned to the treatment and control groups with 28 participants in each group. The participants will be treated with acupunctures or sham procedures at LI15, LI11, ST36, GB34, and ST31, 5 times per week for a total of 20 sessions in 4 weeks while they will receive rehabilitation training. Patients will be followed up every month for 3 months after treatment. The primary outcomes include changes in quadriceps femoris muscle area, thickness, vastus intermediate muscle thickness, subcutaneous tissue thickness, and ultrasonic intensities of the rectus femoris. The secondary outcomes consist of the modified Barthel index score and the Medical Research Council total score. Participants' mechanical ventilation, the rate of detachment at the second week, the 28-day survival rate, and the occurrence of adverse reactions will be measured, and any side effects will be reported and recorded. Patient outcomes between the treatment and control groups will be compared and statistically tested. We anticipate that the therapeutic regimen of acupuncture combined with rehabilitation training would be more effective than the rehabilitation training alone for the treatment of the ICUAW. The findings of this study could help develop a better strategy for the treatment of the ICUAW disease and explore a clinical application of an acupuncture technique. Trial registration: Chinese Clinical Trial Register ChiCTR2000038779. Registered 30 September, 2020, https://www.chictr.org.cn/showproj.aspx?proj=62284.

Incidence, Time Course and Influence on Quality of Life of Intensive Care Unit-Acquired Weakness Symptoms in Long-Term Intensive Care Survivors

PURPOSE

Intensive care unit-acquired weakness (ICUAW) can manifest as muscle weakness or neuropathy-like symptoms, with diagnosis remaining a challenge. Uncertainties surround the long-term cause and sequelae. Therefore, the purpose was to assess incidence, time course and long-term influence on quality of life (QoL) of symptoms in ICU survivors.

METHODS

After ethical approval and registration (www.drks.de: DRKS00011593), in a single-center cohort study all patients admitted to the ICU in 2007-2017 in a German university hospital were screened. Out of 1,860 patients (≥7d ICU care including ventilation support for ≥72 h, at least 6mo-10y after ICU) 636 were deceased, 912 survivors were contacted.

RESULTS

149 former patients (age: 63.5 ± 13.1y; males: 73%; duration in ICU: 20.8 ± 15.7d; duration of ventilation: 16.5 ± 13.7 h; time post-ICU: 4.4 ± 2.7y, 5-10y: 43%) consented to be interviewed concerning occurrence, duration, recovery and consequences of ICUAW-associated muscle weakness or neuropathy-like symptoms after ICU. In 75% at least 1 persistent or previous symmetrical symptom was reported (myopathy-like muscle weakness: 43%; neuropathy-like symptoms: 13%; both: 44%) and rated as incidence of ICUAW. However, only 18% of participants had received an ICUAW diagnosis by their physicians, although 62% had persistent symptoms up to 10y after ICU (5-10y: 46%). Only 37% of participants reported a complete recovery of symptoms, significantly associated with an initially low number of symptoms after ICU (p < 0.0001), myopathy-like symptoms (p = 0.024), and younger age at the time of ICU admission (55.7 ± 13.1 vs. 62.6 ± 10.6y, p < 0.001). ICUAW still impaired the QoL at the time of the interview in 74% of affected survivors, with 30% reporting severe impairment.

CONCLUSION

ICUAW symptoms were disturbingly common in the majority of long-term survivors, indicating that symptoms persist up to 10y and frequently impair QoL. However, only a small number of patients had been diagnosed with ICUAW. Trial registry: Deutsches Register Klinischer Studien (DRKS), https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011593, registration number: DRKS00011593.

Phrenic nerve stimulation prevents diaphragm atrophy in patients with respiratory failure on mechanical ventilation

BACKGROUND

Diaphragm atrophy and dysfunction is a major problem among critically ill patients on mechanical ventilation. Ventilator-induced diaphragmatic dysfunction is thought to play a major role, resulting in a failure of weaning. Stimulation of the phrenic nerves and resulting diaphragm contraction could potentially prevent or treat this atrophy. The subject of this study is to determine the effectiveness of diaphragm stimulation in preventing atrophy by measuring changes in its thickness.

METHODS

A total of 12 patients in the intervention group and 10 patients in the control group were enrolled. Diaphragm thickness was measured by ultrasound in both groups at the beginning of study enrollment (hour 0), after 24 hours, and at study completion (hour 48). The obtained data were then statistically analyzed and both groups were compared.

RESULTS

The results showed that the baseline diaphragm thickness in the interventional group was (1.98 ± 0.52) mm and after 48 hours of phrenic nerve stimulation increased to (2.20 ± 0.45) mm (p=0.001). The baseline diaphragm thickness of (2.00 ± 0.33) mm decreased in the control group after 48 hours of mechanical ventilation to (1.72 ± 0.20) mm (p<0.001).

CONCLUSIONS

Our study demonstrates that induced contraction of the diaphragm by pacing the phrenic nerve not only reduces the rate of its atrophy during mechanical ventilation but also leads to an increase in its thickness - the main determinant of the muscle strength required for spontaneous ventilation and successful ventilator weaning.

TRIAL REGISTRATION

The study was registered with ClinicalTrials.gov (18/06/2018, NCT03559933, https://clinicaltrials.gov/ct2/show/NCT03559933 ).

Mortality after Lung Transplantation for Children Bridged with Extracorporeal Membrane Oxygenation

RATIONALE

Extracorporeal membrane oxygenation (ECMO) is increasingly used to bridge waitlisted children failing conventional respiratory support to lung transplantation.

OBJECTIVES

To compare in-hospital mortality and a composite outcome of 1-year mortality or re-transplantation in children bridged with ECMO with those on mechanical ventilation (MV), and neither support.

METHODS

The United Network for Organ Sharing (UNOS) was used to analyze lung transplant recipients, aged ≤ 20 y, from January 2004 to August 2019. Recipients were categorized according to level of respiratory support at time of transplant, including ECMO, MV, or neither. Multivariable analysis was used to evaluate support type and in-hospital mortality.

RESULTS

Of 1,014 children undergoing lung transplant, 68 (6.7%) required ECMO as a bridge-to-transplant, 144 (14.2%) MV, and 802 (79.1%) neither. Primary diagnosis in the ECMO cohort included cystic fibrosis (43%), pneumonia/ARDS (10.3%), interstitial pulmonary fibrosis (7.4%) and pulmonary hypertension (5.9%). Number of patients bridged with ECMO increased throughout the study period from none in 2004 to 16.7% in 2018. Multivariable analysis showed bridging with both ECMO (aOR = 3.57; 95% CI: 1.42, 8.97) and MV (aOR = 2.67; 95% CI: 1.26, 5.57) increased in-hospital mortality after lung transplantation. However, there was no difference in composite outcome of mortality and re-transplantation at 1-year between the three groups.

CONCLUSIONS

ECMO to bridge children to lung transplantation has increased. Despite this, ECMO is a high-risk bridge strategy for children awaiting lung transplantation. Future research should target interventions that can be focused on improving survival in these patients.

High-dose intravenous immunoglobulins as a therapeutic option in critical illness polyneuropathy accompanying SARS-CoV-2 infection: A case-based review of the literature (Review)

The still ongoing COVID-19 pandemic has exposed the medical community to a number of major challenges. A significant number of patients require admission to intensive care unit (ICU) services due to severe respiratory, thrombotic and septic complications and require long-term hospitalization. Neuromuscular weakness is a common complication in critically ill patients who are treated in ICUs and are mechanically ventilated. This complication is frequently caused by critical illness myopathy (CIM) or critical illness polyneuropathy (CIP) and leads to difficulty in weaning from the ventilator. It is thought to represent an important neurologic manifestation of the systemic inflammatory response syndrome (SIRS). COVID-19 infection is known to trigger strong immune dysregulation, with an intense cytokine storm, as a result, the frequency of CIP is expected to be higher in this setting. The mainstay in the diagnosis of this entity beside the high level of clinical awareness is the electrophysiological examination that provides evidence of axonal motor and sensory polyneuropathy. The present article presents the case of a 54-year-old woman with severe COVID 19 infection who developed neuromuscular weakness, which turned out to be secondary to CIP and was treated successfully with a high dose of human intravenous immunoglobulins. Related to this case, we reviewed the relevant literature data regarding the epidemiology, pathophysiology and clinical features of this important complication and discussed also the treatment options and prognosis.

Building a culture of early mobilization in the pediatric intensive care unit-a nuts and bolts approach

The culture of sedation and immobilization in the pediatric intensive care unit (PICU) is associated with PICU-acquired weakness, delirium, and poor functional, neurocognitive and psychosocial outcomes. A structured approach to introducing physical activity, as early as possible after PICU admission, may prevent these complications and optimize the holistic outcomes of critically ill children. Changing culture and introducing new clinical practice in PICU is complex, but can be approached systematically, using a "nuts and bolts" approach targeting the basic, practical considerations and essential required elements or components. Extending the construction analogy, this article reviews the relevant literature to describe the essential elements required to build and sustain a successful and safe early mobility program in the PICU. Effective early mobilization requires individual patient assessment and goal setting, using a collaborative inter-disciplinary, patient- and family-centered approach, to ensure mobility goals and physical activities are appropriate for the patient's age, condition/s, premorbid function, strength, endurance and developmental level. Early mobility activities for the pediatric age spectrum include active or active-assisted range of motion exercises, neurodevelopmental play, use of mobility devices, in-bed exercises, transfers, sitting or standing tolerance, crawling, pre-gait activities, ambulation and activities of daily living, with a focus on play as function. Although there are few complete contraindications to early mobilization, appropriate precautions and preparation should be taken to mitigate potential safety concerns. Although there are many perceived barriers to early mobilization in the PICU, at the level of patient, provider, institution and knowledge translation; these are not objectively associated with increased risk during mobilization and can be overcome through an engaged process of practice change by all members of the interprofessional clinical team. Early mobility programs could be initiated in PICU as systematic quality improvement initiatives, with established processes to optimize structural, process and system elements and to provide continual feedback, measurement, benchmarking and collaboration; to ultimately impact on measurable patient outcomes. Early, graded, and individually prescribed mobilization should be considered as part of the standard PICU "package of care" for all critically ill and injured children, in order to improve their functional status and quality of life after PICU discharge.

Biomarkers Associated with Failure of Liberation from Oxygen Therapy in Severe COVID-19: A Pilot Study

This study aimed to investigate whether clinical and laboratory biomarkers can identify patients with COVID-19 who are less likely to be liberated from oxygen therapy. This was a retrospective study comparing 18 patients in the weaning failure group with 38 patients in the weaning success group. Weaning failure was defined as death or discharge with an oxygen device before day 28 after hospital admission or requiring oxygen support as of day 28. The median quick Sequential Organ Failure Assessment (qSOFA) score was significantly higher and the median SpO₂/FiO₂ was significantly lower in the weaning failure group. The laboratory biomarkers, procalcitonin (PCT) and D-dimer, were significantly higher in the weaning failure group, as were the biomarkers of endothelial injury, such as angiopoietin-2 (Ang-2) and Ang-2/Ang-1, and tumor necrosis factor-α (TNF-α). Patients’ qSOFA scores, SpO₂/FiO₂, and PCT, D-dimer, Ang-2, Ang-2/Ang-1, endocan (4-day and 7-day increases), and TNF-α levels predicted weaning failure; 7-day endocan levels were the best predictor of weaning failure with an AUC of 0.81 (95% CI, 0.67–0.94). We identified clinical and laboratory parameters, including plasma biomarkers of endothelial injury, that may be considered as biomarkers for predicting failure of liberation from oxygen therapy in patients with severe COVID-19.

Out of Control: The Role of the Ubiquitin Proteasome System in Skeletal Muscle during Inflammation

The majority of critically ill intensive care unit (ICU) patients with severe sepsis develop ICU-acquired weakness (ICUAW) characterized by loss of muscle mass, reduction in myofiber size and decreased muscle strength leading to persisting physical impairment. This phenotype results from a dysregulated protein homeostasis with increased protein degradation and decreased protein synthesis, eventually causing a decrease in muscle structural proteins. The ubiquitin proteasome system (UPS) is the predominant protein-degrading system in muscle that is activated during diverse muscle atrophy conditions, e.g., inflammation. The specificity of UPS-mediated protein degradation is assured by E3 ubiquitin ligases, such as atrogin-1 and MuRF1, which target structural and contractile proteins, proteins involved in energy metabolism and transcription factors for UPS-dependent degradation. Although the regulation of activity and function of E3 ubiquitin ligases in inflammation-induced muscle atrophy is well perceived, the contribution of the proteasome to muscle atrophy during inflammation is still elusive. During inflammation, a shift from standard- to immunoproteasome was described; however, to which extent this contributes to muscle wasting and whether this changes targeting of specific muscular proteins is not well described. This review summarizes the function of the main proinflammatory cytokines and acute phase response proteins and their signaling pathways in inflammation-induced muscle atrophy with a focus on UPS-mediated protein degradation in muscle during sepsis. The regulation and target-specificity of the main E3 ubiquitin ligases in muscle atrophy and their mode of action on myofibrillar proteins will be reported. The function of the standard- and immunoproteasome in inflammation-induced muscle atrophy will be described and the effects of proteasome-inhibitors as treatment strategies will be discussed.

Physical and mental health complications post-COVID-19: Scoping review

OBJECTIVE

Several long-lasting health complications have been reported in previous coronavirus infections. Therefore, the aim of this study was to review studies that evaluated physical and mental health problems post-COVID-19.

METHODS

Articles for inclusion in this scoping review were identified by searching the PubMed, Scopus, Web of Science and Google Scholar databases for items dated from 1 January to 7 November 2020. Observational studies evaluating physical health (musculoskeletal symptoms, functional status) or mental health status with a follow-up period longer than 1 month after discharge or after the onset of symptoms were included.

RESULTS

This scoping review included 34 studies with follow-up periods of up to 3 months post-COVID-19. The most commonly reported physical health problems were fatigue (range 28% to 87%), pain (myalgia 4.5% to 36%), arthralgia (6.0% to 27%), reduced physical capacity (six-minute walking test range 180 to 561 m), and declines in physical role functioning, usual care and daily activities (reduced in 15% to 54% of patients). Common mental health problems were anxiety (range 6.5% to 63%), depression (4% to 31%) and post-traumatic stress disorder (12.1% to 46.9%). Greater fatigue, pain, anxiety and depression were reported in female patients and individuals admitted to intensive care. An overall lower quality of life was seen up to 3 months post-COVID-19.

CONCLUSIONS

This review highlights the presence of several physical and mental health problems up to 3 months post-COVID-19. The findings point to the need for comprehensive evaluation and rehabilitation post-COVID-19 to promote quality of life.

Early postoperative complications in lung transplant recipients

Lung transplantation has become an established therapy for end-stage lung diseases. Early postoperative complications can impact immediate, mid-term, and long-term outcomes. Appropriate management, prevention, and early detection of these early postoperative complications can improve the overall transplant course. In this review, we highlight the incidence, detection, and management of these early postoperative complications in lung transplant recipients.

Functional Outcomes, Goals, and Goal Attainment Amongst Chronically Critically Ill Long-Term Acute Care Hospital Patients

RATIONALE

Chronically critically ill patients admitted to a long-term acute care hospital (LTACH) setting are a vulnerable population of intensive care unit survivors. Little is known of the goals and functional outcomes achieved by patients after rehabilitation in the LTACH setting.

OBJECTIVES

We sought to examine patient goals and functional outcomes, including swallowing function, amongst ICU survivors admitted to an LTACH with a tracheostomy.

METHODS

Prospective observational cohort study of chronic critically ill LTACH patients.

RESULTS

Fifty elderly subjects with a median duration of intubation prior to tracheostomy of 13 days were enrolled. ICU-acquired weakness and cognitive impairment were present in 40 (80%) and 36 (72%) patients, as measured by the Medical Research Council scale and Montreal Cognitive Assessment, respectively. Mental health problems were also common, with 16 (32%) patients experiencing moderate to severe anxiety, 9 (18%) experiencing moderate to severe depression, and 11 (22%) reporting symptoms consistent with PTSD, according to the Hospital Anxiety and Depression Scale and Post-Traumatic Stress Syndrome 10-Questions Inventory, respectively. Pharyngeal dysfunction, as measured by Fiberoptic Endoscopic Evaluation of Swallow exam, was present in 37 (74%) patients. Patient goals, in decreasing order of frequency, included: eating and drinking, speaking, walking, returning home, and toileting. By LTACH discharge, goal attainment was variable, with 97% of those who ranked speaking as important able to speak, 88% able to eat and drink, yet only 21% were walking and 18% were able to self-toilet. Discharge to the home or acute rehabilitation setting, achieved in 52% of the population, was associated with greater strength, as measured by the total MRC score (p=0.002), as well as the EuroQOL domains of mobility (p=0.008) and self-care (p=0.04).

CONCLUSIONS

Goal attainment during this period of recovery was variable. The ability to speak, eat and drink, frequently identified as goals by these patients, were achieved, while functional goals such as walking were rarely achieved. These findings highlight the importance of identifying patient goals and setting realistic expectations informed by functional assessments when rehabilitating this vulnerable patient population in the LTACH and subsequent post-acute care settings.

Pathophysiology and management of critical illness polyneuropathy and myopathy

Critical illness-associated weakness (CIAW) is an umbrella term used to describe a group of neuromuscular disorders caused by severe illness. It can be subdivided into three major classifications based on the component of the neuromuscular system (i.e. peripheral nerves or skeletal muscle or both) that are affected. This includes critical illness polyneuropathy (CIP), critical illness myopathy (CIM), and an overlap syndrome, critical illness polyneuromyopathy (CIPNM). It is a common complication observed in people with critical illness requiring intensive care unit (ICU) admission. Given CIAW is found in individuals experiencing grave illness, it can be challenging to study from a practical standpoint. However, over the past 2 decades, many insights into the pathophysiology of this condition have been made. Results from studies in both humans and animal models have found that a profound systemic inflammatory response and factors related to bioenergetic failure as well as microvascular, metabolic, and electrophysiological alterations underlie the development of CIAW. Current management strategies focus on early mobilization, achieving euglycemia, and nutritional optimization. Other interventions lack sufficient evidence, mainly due to a dearth of large trials. The goal of this Physiology in Medicine article is to highlight important aspects of the pathophysiology of these enigmatic conditions. It is hoped that improved understanding of the mechanisms underlying these disorders will lead to further study and new investigations for novel pharmacologic, nutritional, and exercise-based interventions to optimize patient outcomes.

Bedside voluntary and evoked forces evaluation in intensive care unit patients: a narrative review

Around one third of intensive care unit (ICU) patients will develop severe neuromuscular alterations, known as intensive care unit-acquired weakness (ICUAW), during their stay. The diagnosis of ICUAW is difficult and often delayed as a result of sedation or delirium. Indeed, the clinical evaluation of both Medical Research Council score and maximal voluntary force (e.g., using handgrip and/or handheld dynamometers), two independent predictors of mortality, can be performed only in awake and cooperative patients. Transcutaneous electrical/magnetic stimulation applied over motor nerves combined with the development of dedicated ergometer have recently been introduced in ICU patients in order to propose an early and non-invasive measurement of evoked force. The aim of this narrative review is to summarize the different tools allowing bedside force evaluation in ICU patients and the related experimental protocols. We suggest that non-invasive electrical and/or magnetic evoked force measurements could be a relevant strategy to characterize muscle weakness in the early phase of ICU and diagnose ICUAW.

Functional status of mechanically ventilated COVID-19 survivors at ICU and hospital discharge

BACKGROUND

A significant number of COVID-19 patients have been treated using invasive mechanical ventilation (IMV). The ability to evaluate functional status of COVID-19 survivors early on at ICU and hospital discharge may enable identification of patients who may need medical and rehabilitation interventions.

METHODS

The modified "Mental Status", ICU Mobility, and Barthel Index scores at ICU and hospital discharge were tabulated for 118 COVID-19 survivors treated with invasive mechanical ventilation (IMV). These functional scores were compared with pre-admission functional status, discharge durable medical equipment, discharge medical follow-up recommendation, duration on IMV, duration post-IMV, demographics, comorbidities, laboratory tests, and vital signs at ICU and hospital discharge.

RESULTS

The majority of COVID-19 IMV patients were not functionally independent at hospital discharge (22% discharged with cane or rolling walker, 49% discharged with durable medical equipment, and 14% admitted to a rehabilitation facility), although 94% of these patients were functionally independent prior to COVID-19 illness. Half of the patients were discharged with supplemental oxygen equipment. The most prevalent medical follow-up recommendations were cardiology, vascular medicine, pulmonology, endocrinology, and neurology with many patients receiving multiple medical follow-up recommendations. Functional status improved from ICU discharge to hospital discharge (p < 0.001). Worse functional status at hospital discharge was associated with longer IMV duration, older age, male sex, higher number of comorbidities, and the presence of pre-existing comorbidities including hypertension, diabetes, chronic obstructive pulmonary disease, and immunosuppression (p < 0.05, ANOVA).

CONCLUSIONS

The majority of IMV COVID-19 survivors were not functionally independent at discharge and required significant follow-up medical care. The COVID-19 circumstance has placed constraints on access to in-hospital rehabilitation. These findings underscore the need for prospective studies to ascertain the short- and long-term sequela in COVID-19 survivors.

Prolonged Weaning: S2k Guideline Published by the German Respiratory Society

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.

The Impact of Mechanical Ventilation Duration on the Readmission to Intensive Care Unit: A Population-Based Observational Study

Background

If the duration of mechanical ventilation (MV) is related with the intensive care unit (ICU) readmission must be clarified. The purpose of this study was to elucidate if prolonged MV duration increases ICU readmission rate.

Methods

The present observational cohort study analyzed national healthcare claims data from 2006 to 2015. Critically ill patients who received MV in the ICU were classified into five groups according to the MV duration: MV for <7 days, 7–13 days, 14–20 days, 21–27 days, and ≥28 days. The rate and risk of the ICU readmission were estimated according to the MV duration using the unadjusted and adjusted analyses.

Results

We found that 12,929 patients had at least one episode of MV in the ICU. There was a significant linear relationship between the MV duration and the ICU readmission (R²=0.85, p=0.025). The total readmission rate was significantly higher as the MV duration is prolonged (MV for <7 days, 13.9%; for 7–13 days, 16.7%; for 14–20 days, 19.4%; for 21–27 days, 20.4%; for ≥28 days, 35.7%; p<0.001). The analyses adjusted by covariables and weighted with the multinomial propensity scores showed similar results. In the adjusted regression analysis with a Cox proportional hazards model, the MV duration was significantly related to the ICU readmission (hazard ratio, 1.058 [95% confidence interval, 1.047–1.069], p<0.001).

Conclusion

The rate of readmission to the ICU was significantly higher in patients who received longer durations of the MV in the ICU. In the clinical setting, closer observation of patients discharged from the ICU after prolonged periods of MV is required.

Potential Application of Whole Body Vibration Exercise For Improving The Clinical Conditions of COVID-19 Infected Individuals: A Narrative Review From the World Association of Vibration Exercise Experts (WAVex) Panel

COVID-19 is a highly infectious respiratory disease which leads to several clinical conditions related to the dysfunction of the respiratory system along with other physical and psychological complaints. Severely affected patients are referred to intensive care units (ICUs), limiting their possibilities for physical exercise. Whole body vibration (WBV) exercise is a non-invasive, physical therapy, that has been suggested as part of the procedures involved with pulmonary rehabilitation, even in ICU settings. Therefore, in the current review, the World Association of Vibration Exercise Experts (WAVEX) reviewed the potential of WBV exercise as a useful and safe intervention for the management of infected individuals with COVID-19 by mitigating the inactivity-related declines in physical condition and reducing the time in ICU. Recommendations regarding the reduction of fatigue and the risk of dyspnea, the improvement of the inflammatory and redox status favoring cellular homeostasis and the overall improvement in the quality of life are provided. Finally, practical applications for the use of this paradigm leading to a better prognosis in bed bound and ICU-bound subjects is proposed.

Descriptive Analysis of Extubations Performed in an Emergency Department-based Intensive Care Unit

Introduction

Extubation of appropriate patients in the emergency department (ED) may be a strategy to avoid preventable or short-stay intensive care unit (ICU) admissions, and could allow for increased ventilator and ICU bed availability when demand outweighs supply. Extubation is infrequently performed in the ED, and a paucity of outcome data exists. Our objective was to descriptively analyze characteristics and outcomes of patients extubated in an ED-ICU setting.

Methods

We conducted a retrospective observational study at an academic medical center in the United States. Adult ED patients extubated in the ED-ICU from 2015–2019 were retrospectively included and analyzed.

Results

We identified 202 patients extubated in the ED-ICU; 42% were female and median age was 60.86 years. Locations of endotracheal intubation included the ED (68.3%), outside hospital ED (23.8%), and emergency medical services/prehospital (7.9%). Intubations were performed for airway protection (30.2%), esophagogastroduodenoscopy (27.7%), intoxication/ingestion (17.3%), respiratory failure (13.9%), seizure (7.4%), and other (3.5%). The median interval from ED arrival to extubation was 9.0 hours (interquartile range 6.2–13.6). One patient (0.5%) required unplanned re-intubation within 24 hours of extubation. The attending emergency physician (EP) at the time of extubation was not critical care fellowship trained in the majority (55.9%) of cases. Sixty patients (29.7%) were extubated compassionately; 80% of these died in the ED-ICU, 18.3% were admitted to medical-surgical units, and 1.7% were admitted to intensive care. Of the remaining patients extubated in the ED-ICU (n = 142, 70.3%), zero died in the ED-ICU, 61.3% were admitted to medical-surgical units, 9.9% were admitted to intensive care, and 28.2% were discharged home from the ED-ICU.

Conclusion

Select ED patients were safely extubated in an ED-ICU by EPs. Only 7.4% required ICU admission, whereas if ED extubation had not been pursued most or all patients would have required ICU admission. Extubation by EPs of appropriately screened patients may help decrease ICU utilization, including when demand for ventilators or ICU beds is greater than supply. Future research is needed to prospectively study patients appropriate for ED extubation.

Patient functionality and walking speed after discharge from the intensive care unit

Objective

To measure and compare the functionality of patients after discharge from the intensive care unit and at the time of hospital discharge.

Methods

Quantitative study of a prospective cohort performed between August of 2016 and December of 2017 at a university hospital. A 10-meter walk test was performed at 2 timepoints: after discharge from the intensive care unit and prior to hospital discharge. The data were analyzed using Student's t-test and Pearson or Spearman correlation. Statistical Package for Social Science (SPSS) version 21.0 was used for the analysis, and p ≤ 0.05 was adopted as the level of significance.

Results

Forty patients, with a mean age of 57.1 ± 12.2 years and with a predominance of males (60%), were evaluated. For the post-intensive care unit test, a mean speed of 0.48m/s was observed, and for the pre-hospital discharge test, there was an increase to 0.71m/s, evidencing functional evolution during the hospital stay (p < 0.001).

Conclusion

There was significant improvement in walking speed at the time of hospital discharge when compared to the walking speed at the time of intensive care unit discharge.

[Delirium in intensive care patients : A multiprofessional challenge]

Delirium is the most common form of cerebral dysfunction in intensive care patients and is a medical emergency that must be avoided or promptly diagnosed and treated. According to current knowledge the development of delirium seems to be caused by an interplay between increased vulnerability (predisposition) and simultaneous exposure to delirogenic factors. Since delirium is often overlooked in the clinical routine, a continuous screening for delirium should be performed. Due to the close connection between delirium, agitation and pain, sedation and analgesia must be evaluated at least every 8 h analogous to delirium screening. According to current knowledge, a multifactorial and multiprofessional approach is favored in the prevention and treatment of delirium. Non-pharmaceutical interventions through early mobilization, reorientation, sleep improvement, adequate pain therapy and avoidance of polypharmacy are of great importance. Depending on the clinical picture, different substances are used in symptom-oriented drug treatment of delirium. In order to achieve these diagnostic and therapeutic goals, an interdisciplinary treatment team consisting of intensive care, intensive care physicians, ward pharmacists, physiotherapists, nutrition specialists and psychiatrists is necessary in order to meet the requirements of the patient and their relatives.

Polyneuropathy in Critically Ill Mechanically Ventilated Children: Experience From a Tertiary Care Hospital in North India

OBJECTIVES

To determine the prevalence of critical illness polyneuropathy and its risk factors in critically ill children mechanically ventilated for 7 days or more.

DESIGN

Observational cohort study.

SETTING

PICU of a tertiary care hospital from North India.

PATIENTS

Children 1-15 years old admitted in PICU from June 2016 to September 2017, mechanically ventilated for 7 days or more, excluding those with diagnosed neuromuscular disease, stroke, or spinal pathology.

INTERVENTION

Demographic details, diagnosis, treatment details, and anthropometry at admission and enrolment were recorded. Nerve conduction studies were performed after enrolment and repeated a week later, if the child was still in PICU. Medical Research Council scoring for muscle strength was performed in survivors. Risk factors including Pediatric Index of Mortality-2 score, sepsis, multiple organ dysfunction, hypoalbuminemia, use of steroids, neuromuscular-blocking agents, and vasopressors were recorded. Samples for the level of micronutrients (copper, zinc, folate, and vitamin B12) were collected at the time of enrolling the child and at the time of discharge.

MEASUREMENTS AND MAIN RESULTS

Thirty-two children were enrolled, of whom 29 had features of critical illness polyneuropathy on evaluation at day 8 of mechanical ventilation (prevalence, 90.6% [95% CI, 80.5-100%]). The polyneuropathy was axonal in 26 (81.2%), mixed in one patient (3.1%), and uncharacterized in two (6.2%). Sepsis and multiple organ dysfunction were present in 31 subjects (96.9%). No risk factors for critical illness polyneuropathy could be identified although the study was not sufficiently powered to do so. The difference between serum micronutrient levels (copper, zinc, folate, and vitamin B12) between patients who developed polyneuropathy, and those who did not, was statistically insignificant.

CONCLUSIONS

We observed a high prevalence of critical illness polyneuropathy in children in PICU, mechanically ventilated for 7 days or more; almost all of whom had underlying sepsis.

Repetitive vascular occlusion stimulus (RVOS) versus standard care to prevent muscle wasting in critically ill patients (ROSProx):a study protocol for a pilot randomised controlled trial

BACKGROUND

Forty per cent of critically ill patients are affected by intensive care unit-acquired weakness (ICU-AW), to which skeletal muscle wasting makes a substantial contribution. This can impair outcomes in hospital, and can cause long-term physical disability after hospital discharge. No effective mitigating strategies have yet been identified. Application of a repetitive vascular occlusion stimulus (RVOS) a limb pressure cuff inducing brief repeated cycles of ischaemia and reperfusion, can limit disuse muscle atrophy in both healthy controls and bed-bound patients recovering from knee surgery. We wish to determine whether RVOS might be effective in mitigating against muscle wasting in the ICU. Given that RVOS can also improve vascular function in healthy controls, we also wish to assess such effects in the critically ill. We here describe a pilot study to assess whether RVOS application is safe, tolerable, feasible and acceptable for ICU patients.

METHODS

This is a randomised interventional feasibility trial. Thirty-two ventilated adult ICU patients with multiorgan failure will be recruited within 48 h of admission and randomised to either the intervention arm or the control arm. Intervention participants will receive RVOS twice daily (except only once on day 1) for up to 10 days or until ICU discharge. Serious adverse events and tolerability (pain score) will be recorded; feasibility of trial procedures will be assessed against pre-specified criteria and acceptability by semi-structured interview. Together with vascular function, muscle mass and quality will be assessed using ultrasound and measures of physical function at baseline, on days 6 and 11 of study enrolment, and at ICU and hospital discharge. Blood and urine biomarkers of muscle metabolism, vascular function, inflammation and DNA damage/repair mechanism will also be analysed. The Health questionnaire will be completed 3 months after hospital discharge.

DISCUSSION

If this study demonstrates feasibility, the derived data will be used to inform the design (and sample size) of an appropriately-powered prospective trial to clarify whether RVOS can help preserve muscle mass/improve vascular function in critically ill patients.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN44340629. Registered on 26 October 2017.

Intelligent ICU for Autonomous Patient Monitoring Using Pervasive Sensing and Deep Learning

Currently, many critical care indices are not captured automatically at a granular level, rather are repetitively assessed by overburdened nurses. In this pilot study, we examined the feasibility of using pervasive sensing technology and artificial intelligence for autonomous and granular monitoring in the Intensive Care Unit (ICU). As an exemplary prevalent condition, we characterized delirious patients and their environment. We used wearable sensors, light and sound sensors, and a camera to collect data on patients and their environment. We analyzed collected data to detect and recognize patient's face, their postures, facial action units and expressions, head pose variation, extremity movements, sound pressure levels, light intensity level, and visitation frequency. We found that facial expressions, functional status entailing extremity movement and postures, and environmental factors including the visitation frequency, light and sound pressure levels at night were significantly different between the delirious and non-delirious patients. Our results showed that granular and autonomous monitoring of critically ill patients and their environment is feasible using a noninvasive system, and we demonstrated its potential for characterizing critical care patients and environmental factors.

Twenty-year experience with extracorporeal life support as bridge to lung transplantation

OBJECTIVES

Extracorporeal life support is increasingly used to bridge deteriorating candidates to lung transplantation. Nevertheless, only few systematic reports with a limited number of patients exist describing this practice and its changes over time.

METHODS

We retrospectively reviewed our institutional database and performed an era analysis to identify trends over time and risk factors for mortality. After applying propensity score matching, outcomes of bridged patients were compared with those of standard lung transplantation recipients.

RESULTS

Extracorporeal life support was used in 120 patients as an intention to bridge to lung transplantation. Eleven patients (9.2%) were bridged between 1998 and 2004, 39 patients (32.5%) were bridged between 2005 and 2010, and 70 patients were bridged (58.3%) between 2010 and 2017. In the first era, the main bridging modality was venoarterial-extracorporeal membrane oxygenation (n = 10, 90.9%), whereas venovenous devices were primarily used in later eras (second era: n = 18, 46.2%; third era: n = 39, 55.8%). In the second and third eras, 9 patients (23.1%) and 24 patients (34.3%) could be bridged awake. Short-term outcome was poor in the first era, with only 36.4% of patients discharged alive but improved in later eras (53.8% and 77.1%; P = .002). Extracorporeal life support-bridged patients showed an impaired short-term outcome compared with standard recipients. However, survival conditional on 90 days did not differ among the groups (P = .178). In univariate and multivariate analyses, awake extracorporeal life support was protective for survival, whereas acute retransplantation was a risk factor for mortality.

CONCLUSIONS

Over the past 2 decades, the role of extracorporeal life support bridging evolved from an acute rescue therapy to a semi-elective procedure. Stratified outcome analysis revealed that extracorporeal life support bridging yielded similar long-term survival compared with nonbridged patients.

Acute Confusional States in Hospital

BACKGROUND

Acute confusional state (delirium) is an acute disturbance of brain function. The incidence of such states varies according to the group of patients con- cerned: it ranges from 30% to 80% among patients in intensive care and from 5.1% to 52.2% among surgical patients, depending on the type of procedure. The earlier German term "Durchgangssyndrom" (usually rendered as "transitory psychotic syn- drome") tended to imply a self-limited and thus relatively harmless condition. In fact, however, delirium is associated with longer hospital stays, poorer treatment out- comes, and higher mortality. Approximately 25% of patients who have experienced an acute confusional state have residual cognitive deficits thereafter.

METHODS

This review is based on publications retrieved by a selective search in MEDLINE, PubMed, the Cochrane Library, and in the International Standard Randomised Controlled Trial Number (ISRCTN) registry.

RESULTS

Validated instruments are available for the reliable diagnosis of an acute confusional state, e.g., the Confusion Assessment Method for the ICU (CAM-ICU) for patients in intensive care and the 3D-CAM or CAM-S for patients on regular hospital wards. The prevention and treatment of this condition are achieved primarily by a nonpharmacological, multidimensional approach including early mobilization, reorientation, improvement of sleep, adequate pain relief, and the avoidance of polypharmacy. A meta-analysis has shown that these measures lower the incidence of delirium by 44%. The authors find no basis in the current literature for recommending prophylactic medication, although current data promisingly suggest that the incidence of delirium in surgical patients can be lowered by the perioperative administration of dexmedetomidine (odds ratio 0.35). The pharmaco- therapy of acute confusional states involves a careful choice of drug based on the clinical manifestations in the individual case.

CONCLUSION

The key elements of success in the treatment of acute confusional states in the hospital are adequate prevention, rapid diagnosis, the identification of precipitating factors, and the rapid initiation of both causally oriented and symptom- directed treatment.

Intensive Care Management of the Neuromuscular Patient

Neuromuscular emergencies are a distinct group of acute neurological diseases with distinct characteristic presentations. Patients who suffer from this group of diseases are at immediate risk of losing protection of their native airway as well as aspirating orogastric contents. This is secondary to weakness of the muscles of the oropharynx and respiratory muscles. Although some neuromuscular emergencies such as myasthenia gravis or Guillain-Barré syndrome are well understood, others such as critical illness myopathy and neuropathy are less well characterized. In this chapter, we have discussed the pathophysiology, diagnostic evaluation, and management options in patients who are admitted to the intensive care unit. We have also emphasized the importance of a thorough understanding of the use of pharmacological anesthetic agents in this patient population.

The Lifetime Effects of Injury: Postintensive Care Syndrome and Posttraumatic Stress Disorder

Postintensive care syndrome (PICS) is a heterogeneous syndrome marked by physical, cognitive, and mental health impairments experienced by critical care survivors. It is a syndrome that bears significant human and health care costs. Additional research is needed to identify risk factors and diagnostic, preventative, and treatment strategies for PICS. Trauma intensive care unit patients are particularly vulnerable to posttraumatic stress disorder, which shares some of the adverse long-term consequences of PICS and also requires additional research into effective preventative and management strategies.