A new two-tier strength assessment approach to the diagnosis of weakness in intensive care: An observational study. Critical Care, 2015, 19: 52
Parry, S.M., et al.
http://ccforum.com/content/pdf/s13054-015-0780-5.pdf
Intensive care unit acquired weakness (ICUAW) is a significant problem. There is currently
widespread variability in the methods used for manual muscle testing and handgrip
dynamometry (HGD) to diagnose ICUAW. This study was conducted in two parts. The aims
of this study were: to determine the inter-rater reliability and agreement of manual muscle
strength testing using both isometric and through range techniques using the Medical
Research Council sum-score and a new four-point scale, and to examine the validity of HGD
and determine a cutoff score for the diagnosis of ICUAW for the new four-point scale.Part one involved evaluation of muscle strength by two physical therapists in 29 patients
ventilated >48 hours. Manual strength testing was performed by both physical therapists
using two techniques: isometric and through-range; and two scoring systems: traditional sixpoint
Medical Research Council scale and a new collapsed four-point scale. Part two
involved assessment of handgrip strength conducted on 60 patients. A cut-off score for
ICUAW was identified for the new four-point scoring system. The incidence of ICU-AW was 42% (n = 25/60) in this study (based on HGD). In part one
the highest reliability and agreement was observed for the isometric technique using the fourpoint
scale (intraclass correlation coefficient = 0.90: Kappa = 0.72 respectively). Differences
existed between isometric and through-range scores (mean difference = 1.76 points, P =
0.005). In part two, HGD had a sensitivity of 0.88 and specificity of 0.80 for diagnosing
ICUAW. A cut-off score of 24/36 points was identified for the four-point scale. The isometric technique is recommended with reporting on a collapsed four-point scale.
Because HGD is easy to perform and sensitive we recommend a new two-tier approach to
diagnosing ICUAW that first tests handgrip strength with follow-up strength assessment
using the isometric technique for muscle strength testing if handgrip strength falls below
cutoff scores. Whilst our results for the four-point scale are encouraging, further research is
required to confirm the findings of this study and determine the validity of the four-point
scoring system and cut off score developed.
Friday, 27 February 2015
Early mobilization and recovery in mechanically ventilated patients in the ICU
Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Critical Care, 2015, 19: 81
The TEAM Study Investigators.
http://ccforum.com/content/19/1/81
The aim of this study was to investigate current mobilization practice, strength at ICU discharge and functional recovery at 6 months among mechanically ventilated ICU patients. This was a prospective, multi-centre, cohort study conducted in twelve ICUs in Australia and New Zealand. Patients were previously functionally independent and expected to be ventilated for >48 hours. We measured mobilization during invasive ventilation, sedation depth using the Richmond Agitation and Sedation Scale (RASS), co-interventions, duration of mechanical ventilation, ICU-acquired weakness (ICUAW) at ICU discharge, mortality at day 90, and 6-month functional recovery including return to work. We studied 192 patients (mean age 58.1 ± 15.8 years; mean Acute Physiology and Chronic Health Evaluation (APACHE) (IQR) II score, 18.0 (14 to 24)). Mortality at day 90 was 26.6% (51/192). Over 1,351 study days, we collected information during 1,288 planned early mobilization episodes in patients on mechanical ventilation for the first 14 days or until extubation (whichever occurred first). We recorded the highest level of early mobilization. Despite the presence of dedicated physical therapy staff, no mobilization occurred in 1,079 (84%) of these episodes. Where mobilization occurred, the maximum levels of mobilization were exercises in bed (N = 94, 7%), standing at the bed side (N = 11, 0.9%) or walking (N = 26, 2%). On day three, all patients who were mobilized were mechanically ventilated via an endotracheal tube (N = 10), whereas by day five 50% of the patients mobilized were mechanically ventilated via a tracheostomy tube (N = 18). Early mobilization of patients receiving mechanical ventilation was uncommon. More than 50% of patients discharged from the ICU had developed ICU-acquired weakness, which was associated with death between ICU discharge and day-90.
The TEAM Study Investigators.
http://ccforum.com/content/19/1/81
The aim of this study was to investigate current mobilization practice, strength at ICU discharge and functional recovery at 6 months among mechanically ventilated ICU patients. This was a prospective, multi-centre, cohort study conducted in twelve ICUs in Australia and New Zealand. Patients were previously functionally independent and expected to be ventilated for >48 hours. We measured mobilization during invasive ventilation, sedation depth using the Richmond Agitation and Sedation Scale (RASS), co-interventions, duration of mechanical ventilation, ICU-acquired weakness (ICUAW) at ICU discharge, mortality at day 90, and 6-month functional recovery including return to work. We studied 192 patients (mean age 58.1 ± 15.8 years; mean Acute Physiology and Chronic Health Evaluation (APACHE) (IQR) II score, 18.0 (14 to 24)). Mortality at day 90 was 26.6% (51/192). Over 1,351 study days, we collected information during 1,288 planned early mobilization episodes in patients on mechanical ventilation for the first 14 days or until extubation (whichever occurred first). We recorded the highest level of early mobilization. Despite the presence of dedicated physical therapy staff, no mobilization occurred in 1,079 (84%) of these episodes. Where mobilization occurred, the maximum levels of mobilization were exercises in bed (N = 94, 7%), standing at the bed side (N = 11, 0.9%) or walking (N = 26, 2%). On day three, all patients who were mobilized were mechanically ventilated via an endotracheal tube (N = 10), whereas by day five 50% of the patients mobilized were mechanically ventilated via a tracheostomy tube (N = 18). Early mobilization of patients receiving mechanical ventilation was uncommon. More than 50% of patients discharged from the ICU had developed ICU-acquired weakness, which was associated with death between ICU discharge and day-90.
A video to improve patient and surrogate understanding of cardiopulmonary resuscitation choices in the ICU
A video to improve patient and surrogate understanding of cardiopulmonary choices in the ICU: A randomized controlled trial. Critical Care Medicine, 2015, Vol. 43(3), p.621-29.
Wilson, M.E., et al.
http://journals.lww.com/ccmjournal/Abstract/2015/03000/A_Video_to_Improve_Patient_and_Surrogate.14.aspx
To determine if a video depicting cardiopulmonary resuscitation and resuscitation preference options would improve knowledge and decision making among patients and surrogates in the ICU. A video depicting cardiopulmonary resuscitation and explaining resuscitation preference options was associated with improved knowledge of in-hospital cardiopulmonary resuscitation options and cardiopulmonary resuscitation terminology among patients and surrogate decision makers in the ICU, compared with receiving a pamphlet on cardiopulmonary resuscitation. Patients and surrogates found the video helpful in decision making and would recommend the video to others.
Wilson, M.E., et al.
http://journals.lww.com/ccmjournal/Abstract/2015/03000/A_Video_to_Improve_Patient_and_Surrogate.14.aspx
To determine if a video depicting cardiopulmonary resuscitation and resuscitation preference options would improve knowledge and decision making among patients and surrogates in the ICU. A video depicting cardiopulmonary resuscitation and explaining resuscitation preference options was associated with improved knowledge of in-hospital cardiopulmonary resuscitation options and cardiopulmonary resuscitation terminology among patients and surrogate decision makers in the ICU, compared with receiving a pamphlet on cardiopulmonary resuscitation. Patients and surrogates found the video helpful in decision making and would recommend the video to others.
Can yeast isolation be predicted in complicated secondary non-postoperative intra-abdominal infections?
Can yeast isolation be predicted in complicated secondary non-postoperative intra-abdominal infections? Critical Care 2015, 19: 60
Dupont, H., et al.
http://ccforum.com/content/pdf/s13054-015-0790-3.pdf
The aim of this study was to create a predictive score for yeast isolation in patients with complicated non-postoperative intra-abdominal infections (CNPIAI) and to evaluate the impact of yeast isolation on outcome. All patients with a CNPIAI undergoing emergency surgery over a 3-year period were included in the retrospective cohort (RC, n = 290). Patients with a yeast-positive peritoneal fluid culture (YP) were compared with patients with a yeast-negative culture (YN). Multivariate logistic regression was used to identify factors independently associated with yeast isolation and a predictive score was built. The score’s performance was then established in the prospective cohort (PC, n = 152) over an 18-month period. Outcome of the whole cohort was evaluated and independent risks factors of mortality searched.
Dupont, H., et al.
http://ccforum.com/content/pdf/s13054-015-0790-3.pdf
The aim of this study was to create a predictive score for yeast isolation in patients with complicated non-postoperative intra-abdominal infections (CNPIAI) and to evaluate the impact of yeast isolation on outcome. All patients with a CNPIAI undergoing emergency surgery over a 3-year period were included in the retrospective cohort (RC, n = 290). Patients with a yeast-positive peritoneal fluid culture (YP) were compared with patients with a yeast-negative culture (YN). Multivariate logistic regression was used to identify factors independently associated with yeast isolation and a predictive score was built. The score’s performance was then established in the prospective cohort (PC, n = 152) over an 18-month period. Outcome of the whole cohort was evaluated and independent risks factors of mortality searched.
Monday, 23 February 2015
Dexmedetomidine versus standard care sedation with propofol or midazolam in intensive care
Dexmedetomidine versus standard care sedation with propofol or midazolam in intensive care - an economic evaluation. Critical Care 2015, 19: 67
Turunen, H., et al.
http://ccforum.com/content/19/1/67/abstract
Dexmedetomidine was shown in two European randomized double-blind double-dummy trials (PRODEX and MIDEX) to be non-inferior to propofol and midazolam in maintaining target sedation levels in mechanically ventilated intensive care unit (ICU) patients. Additionally, dexmedetomidine shortened the time to extubation versus both standard sedatives, suggesting it may reduce ICU resource needs and thus lower ICU costs.
Turunen, H., et al.
http://ccforum.com/content/19/1/67/abstract
Dexmedetomidine was shown in two European randomized double-blind double-dummy trials (PRODEX and MIDEX) to be non-inferior to propofol and midazolam in maintaining target sedation levels in mechanically ventilated intensive care unit (ICU) patients. Additionally, dexmedetomidine shortened the time to extubation versus both standard sedatives, suggesting it may reduce ICU resource needs and thus lower ICU costs.
Transferring the critically ill patient
Transferring the critically ill patient: Are we there yet? Critical Care, 2015, 19: 62.
Droogh, J.M., et al.
http://ccforum.com/content/19/1/62
During the past few decades the numbers of ICUs and beds has increased significantly, but so too has the demand for intensive care. Currently large, and increasing, numbers of critically ill patients require transfer between critical care units. Inter-unit transfer poses significant risks to critically ill patients, particularly those requiring multiple organ support. While the safety and quality of inter-unit and hospital transfers appear to have improved over the years, the effectiveness of specific measures to improve safety have not been confirmed by randomized controlled trials. It is generally accepted that critically ill patients should be transferred by specialized retrieval teams, but the composition, training and assessment of these teams is still a matter of debate. Since it is likely that the numbers and complexity of these transfers will increase in the near future, further studies are warranted.
Droogh, J.M., et al.
http://ccforum.com/content/19/1/62
During the past few decades the numbers of ICUs and beds has increased significantly, but so too has the demand for intensive care. Currently large, and increasing, numbers of critically ill patients require transfer between critical care units. Inter-unit transfer poses significant risks to critically ill patients, particularly those requiring multiple organ support. While the safety and quality of inter-unit and hospital transfers appear to have improved over the years, the effectiveness of specific measures to improve safety have not been confirmed by randomized controlled trials. It is generally accepted that critically ill patients should be transferred by specialized retrieval teams, but the composition, training and assessment of these teams is still a matter of debate. Since it is likely that the numbers and complexity of these transfers will increase in the near future, further studies are warranted.
The impact of hospital and ICU organizational factors on outcome in critically ill patients
The impact of hospital and ICU organizational factors on outcome in critically ill patients: Results from the extended prevalence of infection in intensive care study. Critical Care Medicine, March 2015, Vol. 43(3), p.519-26.
Sakr, Y., et al.
http://journals.lww.com/ccmjournal/Abstract/2015/03000/The_Impact_of_Hospital_and_ICU_Organizational.2.aspx
To investigate the impact of various facets of ICU organization on outcome in a large cohort of ICU patients from different geographic regions.
Sakr, Y., et al.
http://journals.lww.com/ccmjournal/Abstract/2015/03000/The_Impact_of_Hospital_and_ICU_Organizational.2.aspx
To investigate the impact of various facets of ICU organization on outcome in a large cohort of ICU patients from different geographic regions.
The efficacy and safety of Heparin in patients with sepsis
The efficacy and safety of Heparin in patients with sepsis. Critical Care Medicine, March 2015, Vol. 43(3), p.511-18.
Zarychanski, R., et al.
http://journals.lww.com/ccmjournal/Abstract/2015/03000/The_Efficacy_and_Safety_of_Heparin_in_Patients.1.aspx
To evaluate the efficacy and safety of heparin in patients with sepsis, septic shock, or disseminated intravascular coagulation associated with infection.
Zarychanski, R., et al.
http://journals.lww.com/ccmjournal/Abstract/2015/03000/The_Efficacy_and_Safety_of_Heparin_in_Patients.1.aspx
To evaluate the efficacy and safety of heparin in patients with sepsis, septic shock, or disseminated intravascular coagulation associated with infection.
Prevalence, risk factors and outcomes of delirium in mechanically ventilated adults
Prevalence, risk factors and outcomes of delirium in mechanically ventilated adults. Critical Care Medicine, March 2015, Vol. 43(3), p.557-66.
Mehta, S., et al.
http://journals.lww.com/ccmjournal/Abstract/2015/03000/Prevalence,_Risk_Factors,_and_Outcomes_of_Delirium.7.aspx
Delirium is common during critical illness and associated with adverse outcomes. We compared characteristics and outcomes of delirious and nondelirious patients enrolled in a multicenter trial comparing protocolized sedation with protocolized sedation plus daily sedation interruption.
Mehta, S., et al.
http://journals.lww.com/ccmjournal/Abstract/2015/03000/Prevalence,_Risk_Factors,_and_Outcomes_of_Delirium.7.aspx
Delirium is common during critical illness and associated with adverse outcomes. We compared characteristics and outcomes of delirious and nondelirious patients enrolled in a multicenter trial comparing protocolized sedation with protocolized sedation plus daily sedation interruption.
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