Functional outcomes in ICU - what should we be using? An observational study. Critical Care 2015, 19: 127
Parry, S.M., et al.
http://ccforum.com/content/19/1/127
With growing awareness of the importance of rehabilitation, new measures are being developed specifically for use in the intensive care unit (ICU). There are currently 26 measures reported to assess function in ICU survivors. The Physical Function in Intensive care Test scored (PFIT-s) has established clinimetric properties. It is unknown how other functional measures perform in comparison to the PFIT-s or which functional measure may be the most clinically applicable for use within the ICU. The aims of this study were to determine (1) the criterion validity of the Functional Status Score for the ICU (FSS-ICU), ICU Mobility Scale (IMS) and Short Physical Performance Battery (SPPB) against the PFIT-s; (2) the construct validity of these tests against muscle strength; (3) predictive utility of these tests to predict discharge to home; and (4) the clinical applicability. This was a nested study within an ongoing controlled study and an observational study. Results: Mean ± SD PFIT-s at awakening was 4.7 ± 2.3 out of 10. On awakening a large positive relationship existed between PFIT-s and the other functional measures: FSS-ICU (rho = 0.87, p < 0.005), IMS (rho = 0.81, p < 0.005) and SPPB (rho = 0.70, p < 0.005). The PFIT-s had excellent construct validity (rho = 0.8, p < 0.005) and FSS-ICU (rho = 0.69, p < 0.005) and IMS (rho = 0.57, p < 0.005) had moderate construct validity with muscle strength. There is high criterion validity for other functional measures against the PFIT-s. The PFIT-s and FSS-ICU are promising functional measures and are recommended to measure function within the ICU.
Tuesday, 28 April 2015
Renal tubular acidosis is highly prevalent in critically ill patients
Renal tubular acidosis is highly prevalent in critically ill patients. Critical Care 2015, 19: 148
Brunner, R., et al.
http://ccforum.com/content/19/1/148
Hyperchloremic acidosis is frequent in critically ill patients. Renal tubular acidosis (RTA) may contribute to acidemia in the state of hyperchloremic acidosis, but the prevalence of RTA has never been studied in critically ill patients. Therefore, we aimed to investigate the prevalence, type, and possible risk factors of RTA in critically ill patients using a physical-chemical approach. Results: During the first week of ICU stay 43 of the patients presented with hyperchloremic acidosis on one or more days represented as pronounced negative BEChloride. In 31 patients hyperchloremic acidosis was associated with RTA characterized by a UOG ≤150 mosmol/kg in combination with preserved renal function. However, in 26 of the 31 patients with RTA metabolic acidosis was neutralized by other acid-base disturbances leading to a normal arterial pH. Conclusions: RTA is highly prevalent in critically ill patients with hyperchloremic acidosis, whereas it is often neutralized by the simultaneous occurrence of other acid-base disturbances.
Brunner, R., et al.
http://ccforum.com/content/19/1/148
Hyperchloremic acidosis is frequent in critically ill patients. Renal tubular acidosis (RTA) may contribute to acidemia in the state of hyperchloremic acidosis, but the prevalence of RTA has never been studied in critically ill patients. Therefore, we aimed to investigate the prevalence, type, and possible risk factors of RTA in critically ill patients using a physical-chemical approach. Results: During the first week of ICU stay 43 of the patients presented with hyperchloremic acidosis on one or more days represented as pronounced negative BEChloride. In 31 patients hyperchloremic acidosis was associated with RTA characterized by a UOG ≤150 mosmol/kg in combination with preserved renal function. However, in 26 of the 31 patients with RTA metabolic acidosis was neutralized by other acid-base disturbances leading to a normal arterial pH. Conclusions: RTA is highly prevalent in critically ill patients with hyperchloremic acidosis, whereas it is often neutralized by the simultaneous occurrence of other acid-base disturbances.
Nebulized antibiotics for ventilator-associated pneumonia
Nebulized antibiotics for ventilator-associated pneumonia: A systematic review and meta-analaysis.
Critical Care 2015, 19: 150
Zampieri, F.G., et al.
http://ccforum.com/content/19/1/150
Nebulized antibiotics are a promising new treatment option for ventilator-associated pneumonia. However, more evidence of the benefit of this therapy is required. Results: Twelve studies were analyzed, including six randomized controlled trials. For the main outcome analysis, 812 patients were included. Nebulized antibiotics were associated with higher rates of clinical cure (risk ratio (RR) = 1.23; 95% confidence interval (CI), 1.05 to 1.43; I2 = 34%; D2 = 45%). Nebulized antibiotics were not associated with microbiological cure (RR = 1.24; 95% CI, 0.95 to 1.62; I2 = 62.5), mortality (RR = 0.90; CI 95%, 0.76 to 1.08; I2 = 0%), duration of mechanical ventilation (standardized mean difference = −0.10 days; 95% CI, −1.22 to 1.00; I2 = 96.5%), ICU length of stay (standardized mean difference = 0.14 days; 95% CI, −0.46 to 0.73; I2 = 89.2%) or renal toxicity (RR = 1.05; 95% CI, 0.70 to 1.57; I2 = 15.6%). Regarding the primary outcome, the number of patients included was below the information size required for a definitive conclusion by trial sequential analysis; therefore, our results regarding this parameter are inconclusive. Conclusion: Nebulized antibiotics seem to be associated with higher rates of clinical cure in the treatment of ventilator-associated pneumonia. However, the apparent benefit in the clinical cure rate observed by traditional meta-analysis does not persist after trial sequential analysis. Additional high-quality studies on this subject are highly warranted.
Critical Care 2015, 19: 150
Zampieri, F.G., et al.
http://ccforum.com/content/19/1/150
Nebulized antibiotics are a promising new treatment option for ventilator-associated pneumonia. However, more evidence of the benefit of this therapy is required. Results: Twelve studies were analyzed, including six randomized controlled trials. For the main outcome analysis, 812 patients were included. Nebulized antibiotics were associated with higher rates of clinical cure (risk ratio (RR) = 1.23; 95% confidence interval (CI), 1.05 to 1.43; I2 = 34%; D2 = 45%). Nebulized antibiotics were not associated with microbiological cure (RR = 1.24; 95% CI, 0.95 to 1.62; I2 = 62.5), mortality (RR = 0.90; CI 95%, 0.76 to 1.08; I2 = 0%), duration of mechanical ventilation (standardized mean difference = −0.10 days; 95% CI, −1.22 to 1.00; I2 = 96.5%), ICU length of stay (standardized mean difference = 0.14 days; 95% CI, −0.46 to 0.73; I2 = 89.2%) or renal toxicity (RR = 1.05; 95% CI, 0.70 to 1.57; I2 = 15.6%). Regarding the primary outcome, the number of patients included was below the information size required for a definitive conclusion by trial sequential analysis; therefore, our results regarding this parameter are inconclusive. Conclusion: Nebulized antibiotics seem to be associated with higher rates of clinical cure in the treatment of ventilator-associated pneumonia. However, the apparent benefit in the clinical cure rate observed by traditional meta-analysis does not persist after trial sequential analysis. Additional high-quality studies on this subject are highly warranted.
Severe and multiple hypoglycemic episodes are associated with increased risk of death in ICU patients
Severe and multiple hypoglycemic episodes are associated with increased risk of death in ICU patients. Critical Care 2015, 19: 153
Kalfon, P., et al.
http://ccforum.com/content/pdf/s13054-015-0851-7.pdf
Using a randomized controlled trial comparing tight glucose control with a computerized decision-support systems and conventional protocols (post hoc analysis), we tested the hypothesis that hypoglycemia is associated with a poor outcome, even when controlling for initial severity. We looked for moderate (2.2-3.3 mmol/l) and severe (<2.2 mmol/l) hypoglycemia, multiple hypoglycemic events (n ≥ 3), and the other main components of glycemic control (mean blood glucose level and blood glucose coefficient of variation (CV)). The primary end-point was 90-day mortality. We used both a multivariable analysis taking into account only variables observed at admission and a multivariable matching process (greedy matching algorithm, caliper width of 10−5 digit with no replacement). Results: A total of 2,601 patients were analyzed and divided into three groups: no hypoglycemia (n = 1,474), moderate hypoglycemia (n = 874, 34%), and severe hypoglycemia (n = 253, 10%). Patients with moderate or severe hypoglycemia had a poorer prognosis as shown by a higher mortality rate (36% and 54% respectively, vs. 28%) and decreased number of treatment-free days. In the multivariable analysis, severe (OR 1.50, 95% CI 1.36-1.56, P = 0.043) and multiple hypoglycemic events (OR 1.76, 95% CI 1.31-3.37, P < 0.001) were significantly associated with mortality whereas blood glucose CV was not. Using multivariable matching, patients with severe (53 vs. 35%, P < 0.001), moderate (33 vs. 27%, P = 0.029), and multiple hypoglycemic events (46 vs. 32%, P < 0.001), had a higher 90-day mortality. Conclusion: In a large cohort of ICU patients, severe hypoglycemia and multiple hypoglycemic events were associated with increased 90-day mortality.
Kalfon, P., et al.
http://ccforum.com/content/pdf/s13054-015-0851-7.pdf
Using a randomized controlled trial comparing tight glucose control with a computerized decision-support systems and conventional protocols (post hoc analysis), we tested the hypothesis that hypoglycemia is associated with a poor outcome, even when controlling for initial severity. We looked for moderate (2.2-3.3 mmol/l) and severe (<2.2 mmol/l) hypoglycemia, multiple hypoglycemic events (n ≥ 3), and the other main components of glycemic control (mean blood glucose level and blood glucose coefficient of variation (CV)). The primary end-point was 90-day mortality. We used both a multivariable analysis taking into account only variables observed at admission and a multivariable matching process (greedy matching algorithm, caliper width of 10−5 digit with no replacement). Results: A total of 2,601 patients were analyzed and divided into three groups: no hypoglycemia (n = 1,474), moderate hypoglycemia (n = 874, 34%), and severe hypoglycemia (n = 253, 10%). Patients with moderate or severe hypoglycemia had a poorer prognosis as shown by a higher mortality rate (36% and 54% respectively, vs. 28%) and decreased number of treatment-free days. In the multivariable analysis, severe (OR 1.50, 95% CI 1.36-1.56, P = 0.043) and multiple hypoglycemic events (OR 1.76, 95% CI 1.31-3.37, P < 0.001) were significantly associated with mortality whereas blood glucose CV was not. Using multivariable matching, patients with severe (53 vs. 35%, P < 0.001), moderate (33 vs. 27%, P = 0.029), and multiple hypoglycemic events (46 vs. 32%, P < 0.001), had a higher 90-day mortality. Conclusion: In a large cohort of ICU patients, severe hypoglycemia and multiple hypoglycemic events were associated with increased 90-day mortality.
A systematic review of implementation strategies for assessment, prevention and management of ICU delirium and their effect on clinical outcomes
A systematic review of implementation strategies for assessment, prevention and management of ICU delirium and their effect on clinical outcomes. Critical Care 2015, 19: 157
Trogrlic, Z., et al.
http://ccforum.com/content/pdf/s13054-015-0886-9.pdf
Despite recommendations from professional societies and patient safety organizations, the majority of ICU patients worldwide are not routinely monitored for delirium, thus preventing timely prevention and management. The purpose of this systematic review is to summarize what types of implementation strategies have been tested to improve ICU clinicians’ ability to effectively assess, prevent and treat delirium and to evaluate the effect of these strategies on clinical outcomes. Results: We included 21 studies, all including process measures, while 9 reported both process measures and clinical outcomes. Some individual strategies such as “audit and feedback” and “tailored interventions” may be important to establish clinical outcome improvements, but otherwise robust data on effectiveness of specific implementation strategies were scarce. Successful implementation interventions were frequently reported to change process measures, such as improvements in adherence to delirium screening with up to 92%, but relating process measures to outcome changes was generally not possible. In meta-analyses, reduced mortality and ICU length of stay reduction were statistically more likely with implementation programs that employed more (six or more) rather than less implementation strategies and when a framework was used that either integrated current evidence on pain, agitation and delirium management (PAD) or when a strategy of early awakening, breathing, delirium screening and early exercise (ABCDE bundle) was employed. Using implementation strategies aimed at organizational change, next to behavioural change ,was also associated with reduced mortality. Conclusion: Our findings may indicate that multi-component implementation programs with a higher number of strategies targeting ICU delirium assessment, prevention and treatment and integrated within PAD or ABCDE bundle have the potential to improve clinical outcomes. However, prospective confirmation of these findings is needed to inform the most effective implementation practice with regard to integrated delirium management and such research should clearly delineate effective practice change from improvements in clinical outcomes.
Trogrlic, Z., et al.
http://ccforum.com/content/pdf/s13054-015-0886-9.pdf
Despite recommendations from professional societies and patient safety organizations, the majority of ICU patients worldwide are not routinely monitored for delirium, thus preventing timely prevention and management. The purpose of this systematic review is to summarize what types of implementation strategies have been tested to improve ICU clinicians’ ability to effectively assess, prevent and treat delirium and to evaluate the effect of these strategies on clinical outcomes. Results: We included 21 studies, all including process measures, while 9 reported both process measures and clinical outcomes. Some individual strategies such as “audit and feedback” and “tailored interventions” may be important to establish clinical outcome improvements, but otherwise robust data on effectiveness of specific implementation strategies were scarce. Successful implementation interventions were frequently reported to change process measures, such as improvements in adherence to delirium screening with up to 92%, but relating process measures to outcome changes was generally not possible. In meta-analyses, reduced mortality and ICU length of stay reduction were statistically more likely with implementation programs that employed more (six or more) rather than less implementation strategies and when a framework was used that either integrated current evidence on pain, agitation and delirium management (PAD) or when a strategy of early awakening, breathing, delirium screening and early exercise (ABCDE bundle) was employed. Using implementation strategies aimed at organizational change, next to behavioural change ,was also associated with reduced mortality. Conclusion: Our findings may indicate that multi-component implementation programs with a higher number of strategies targeting ICU delirium assessment, prevention and treatment and integrated within PAD or ABCDE bundle have the potential to improve clinical outcomes. However, prospective confirmation of these findings is needed to inform the most effective implementation practice with regard to integrated delirium management and such research should clearly delineate effective practice change from improvements in clinical outcomes.
Paracetamol therapy and outcome of critically ill patients
Paracetamol therapy and outcome of critically ill patients: a multicentre retrospective observational study. Critical Care 2015, 19: 162.
Suzuki, S., et al.
http://ccforum.com/content/pdf/s13054-015-0865-1.pdf
We conducted a multicenter retrospective observational study in four ICUs. We obtained information on paracetamol use, body temperature, demographic, clinical and outcome data from each hospital’s clinical information system and admissions and discharges database. We performed statistical analysis to assess the association between paracetamol administration and hospital mortality. Results: We studied 15,818 patients with 691,348 temperature measurements from 4 ICUs. Of these patients, 10,046 (64%) received at least one gram of paracetamol. Patients who received paracetamol had lower in-hospital mortality (10% vs. 20%, p <0.001) and survivors were more likely to have received paracetamol (66% vs. 46%; p < 0.001). However, paracetamol-treated patients were also more likely to be admitted to ICU after surgery (70% vs. 51%; p < 0.001) and/or after elective surgery (55% vs. 37%; p < 0.001). On multivariate logistic regression analysis including a propensity score for paracetamol treatment, we found a significant and independent association between the use of paracetamol and reduced in-hospital mortality (Adjusted odds ratio 0.60 [95%CI 0.53-0.68], p < 0.001). Cox-proportional hazards analysis showed that patients who received paracetamol also had a significantly longer time to death (Adjusted hazard ratio 0.51 [95%CI 0.46-0.56], P <0.001). The association between paracetamol and decreased mortality and/or time to death was broadly consistent across surgical and medical patients. It remained present after adjusting for paracetamol administration as a time dependent variable. However, when such time-dependent analysis was performed, the association of paracetamol with outcome lost statistical significance in the presence of fever, suspected infection and in patients in the lower tertiles of Acute Physiology and Chronic Health Evaluation (APACHE II) scores. Conclusions: Paracetamol administration is common in ICU and appears independently associated with reduced in-hospital mortality and time to death after adjustment for multiple potential confounders and propensity score. This association, however, was modified by the presence of fever, suspected infection and lesser illness severity and may represent the effect of indication bias.
Suzuki, S., et al.
http://ccforum.com/content/pdf/s13054-015-0865-1.pdf
We conducted a multicenter retrospective observational study in four ICUs. We obtained information on paracetamol use, body temperature, demographic, clinical and outcome data from each hospital’s clinical information system and admissions and discharges database. We performed statistical analysis to assess the association between paracetamol administration and hospital mortality. Results: We studied 15,818 patients with 691,348 temperature measurements from 4 ICUs. Of these patients, 10,046 (64%) received at least one gram of paracetamol. Patients who received paracetamol had lower in-hospital mortality (10% vs. 20%, p <0.001) and survivors were more likely to have received paracetamol (66% vs. 46%; p < 0.001). However, paracetamol-treated patients were also more likely to be admitted to ICU after surgery (70% vs. 51%; p < 0.001) and/or after elective surgery (55% vs. 37%; p < 0.001). On multivariate logistic regression analysis including a propensity score for paracetamol treatment, we found a significant and independent association between the use of paracetamol and reduced in-hospital mortality (Adjusted odds ratio 0.60 [95%CI 0.53-0.68], p < 0.001). Cox-proportional hazards analysis showed that patients who received paracetamol also had a significantly longer time to death (Adjusted hazard ratio 0.51 [95%CI 0.46-0.56], P <0.001). The association between paracetamol and decreased mortality and/or time to death was broadly consistent across surgical and medical patients. It remained present after adjusting for paracetamol administration as a time dependent variable. However, when such time-dependent analysis was performed, the association of paracetamol with outcome lost statistical significance in the presence of fever, suspected infection and in patients in the lower tertiles of Acute Physiology and Chronic Health Evaluation (APACHE II) scores. Conclusions: Paracetamol administration is common in ICU and appears independently associated with reduced in-hospital mortality and time to death after adjustment for multiple potential confounders and propensity score. This association, however, was modified by the presence of fever, suspected infection and lesser illness severity and may represent the effect of indication bias.
Post traumatic stress disorder in critical illness survivors
Post traumatic stress disorder in critical illness survivors: A meta-analysis. Critical Care Medicine, May 2015, Vol. 43(5), p. 1121-29.
Parker, A.M., et al.
http://journals.lww.com/ccmjournal/Abstract/2015/05000/Posttraumatic_Stress_Disorder_in_
Critical_Illness.25.aspx
Objective: To conduct a systematic review and metaanalysis of the prevalence, risk factors, and prevention/treatment strategies for posttraumatic stress disorder symptoms in critical illness survivors. Conclusions: Clinically important posttraumatic stress disorder symptoms occurred in one fifth of critical illness survivors at 1-year follow-up, with higher prevalence in those who had comorbid psychopathology, received benzodiazepines, and had early memories of frightening ICU experiences. In European studies, ICU diaries reduced posttraumatic stress disorder symptoms.
Parker, A.M., et al.
http://journals.lww.com/ccmjournal/Abstract/2015/05000/Posttraumatic_Stress_Disorder_in_
Critical_Illness.25.aspx
Objective: To conduct a systematic review and metaanalysis of the prevalence, risk factors, and prevention/treatment strategies for posttraumatic stress disorder symptoms in critical illness survivors. Conclusions: Clinically important posttraumatic stress disorder symptoms occurred in one fifth of critical illness survivors at 1-year follow-up, with higher prevalence in those who had comorbid psychopathology, received benzodiazepines, and had early memories of frightening ICU experiences. In European studies, ICU diaries reduced posttraumatic stress disorder symptoms.
Do alcohol misuse disorders impact on long term outcomes from intensive care?
Do alcohol misuse disorders impact on long term outcomes from intensive care? A prospective observational cohort study. Critical Care 2015, 19: 185
McPeake, J.M., et al.
http://ccforum.com/content/pdf/s13054-015-0909-6.pdf
There is limited evidence regarding the impact of alcohol use disorders on long term outcomes from intensive care. The aims of this study were to analyse the nature and complications of alcohol related admissions to intensive care and determine whether alcohol use disorders impact on survival at six months post ICU discharge. Method: An 18 month prospective observational cohort study in a 20 bedded mixed ICU, in a large teaching hospital in Scotland. On admission patients were allocated to one of three alcohol groups: low risk, harmful/hazardous, or alcohol dependency. Results: 34.4% of patients were admitted with an alcohol use disorder. Those with an alcohol related admission (either harmful/hazardous or alcohol dependent) had an increased odds of developing septic shock during their admission, compared with the low risk group (OR 1.67; 95% CI 1.13-2.47, p = 0.01). After adjustment for all lifestyle factors which were significantly different between the groups, alcohol dependence was associated with more than a twofold increased odds of ICU mortality (OR 2.28; 95% CI 1.2-4.69, p = 0.01) and hospital mortality (OR 2.43; 95% CI 1.28-4.621, p = 0.004). After adjustment for deprivation category and age, alcohol dependence was associated with an almost two fold increased odds of mortality at six months post ICU discharge (HR 1.86; CI 1.30-2.70, p = 0.001). Conclusion: Alcohol use disorders are a significant risk factor for the development of septic shock in intensive care. Further, alcohol dependency is independently associated with poorer long term outcomes from intensive care.
McPeake, J.M., et al.
http://ccforum.com/content/pdf/s13054-015-0909-6.pdf
There is limited evidence regarding the impact of alcohol use disorders on long term outcomes from intensive care. The aims of this study were to analyse the nature and complications of alcohol related admissions to intensive care and determine whether alcohol use disorders impact on survival at six months post ICU discharge. Method: An 18 month prospective observational cohort study in a 20 bedded mixed ICU, in a large teaching hospital in Scotland. On admission patients were allocated to one of three alcohol groups: low risk, harmful/hazardous, or alcohol dependency. Results: 34.4% of patients were admitted with an alcohol use disorder. Those with an alcohol related admission (either harmful/hazardous or alcohol dependent) had an increased odds of developing septic shock during their admission, compared with the low risk group (OR 1.67; 95% CI 1.13-2.47, p = 0.01). After adjustment for all lifestyle factors which were significantly different between the groups, alcohol dependence was associated with more than a twofold increased odds of ICU mortality (OR 2.28; 95% CI 1.2-4.69, p = 0.01) and hospital mortality (OR 2.43; 95% CI 1.28-4.621, p = 0.004). After adjustment for deprivation category and age, alcohol dependence was associated with an almost two fold increased odds of mortality at six months post ICU discharge (HR 1.86; CI 1.30-2.70, p = 0.001). Conclusion: Alcohol use disorders are a significant risk factor for the development of septic shock in intensive care. Further, alcohol dependency is independently associated with poorer long term outcomes from intensive care.
Impact of ICU-acquired weakness on post-ICU physical functioning
Impact of ICU-acquired weakness on post-ICU physical functioning: a follow-up study. Critical Care 2015, 19: 196
Wieske, L., et al.
http://ccforum.com/content/pdf/s13054-015-0937-2.pdf
Intensive Care Unit – acquired weakness (ICU-AW) is thought to mediate physical impairments in survivors of critical illness but few studies have investigated this thoroughly. The purpose was to investigate differences in post-ICU mortality and physical functioning between patients with and without ICU-AW at 6 months after ICU discharge. Method ICU patients, mechanically ventilated ≥2 days, were included in a single center prospective observational cohort study. ICU-AW was diagnosed when the average Medical Research Council (MRC) score was <4 in awake and attentive patients. Post-ICU mortality was recorded until 6 months after ICU discharge; in surviving patients physical functioning was assessed using the Short-Form Health Survey (SF-36) physical functioning (PF) domain. The independent effect of ICU-AW on post-ICU mortality was analyzed using a multivariable Cox proportional hazards model. The independent effect of ICU-AW on the PF domain score was analyzed using a multivariable linear regression model. Results: 156 patients were included, of whom 80 with ICU-AW. Twenty-three patients died in the ICU (20 with ICU-AW); during the 6 months follow-up after ICU discharge another 25 patients died (17 with ICU-AW). PF scores were available for 96 survivors (39 patients with ICU-AW). ICU-AW was independently associated with an increase in post-ICU mortality (HR 3.6 (95% CI: 1.3 to 9.8); p:0.01) and with a decrease in physical functioning (β: -16.7 points (95% CI: -30.2 to -3.1); p:0.02). Conclusion: ICU-AW is independently associated with higher post-ICU mortality and with clinically relevant lower physical functioning in survivors at 6 months after ICU discharge.
Wieske, L., et al.
http://ccforum.com/content/pdf/s13054-015-0937-2.pdf
Intensive Care Unit – acquired weakness (ICU-AW) is thought to mediate physical impairments in survivors of critical illness but few studies have investigated this thoroughly. The purpose was to investigate differences in post-ICU mortality and physical functioning between patients with and without ICU-AW at 6 months after ICU discharge. Method ICU patients, mechanically ventilated ≥2 days, were included in a single center prospective observational cohort study. ICU-AW was diagnosed when the average Medical Research Council (MRC) score was <4 in awake and attentive patients. Post-ICU mortality was recorded until 6 months after ICU discharge; in surviving patients physical functioning was assessed using the Short-Form Health Survey (SF-36) physical functioning (PF) domain. The independent effect of ICU-AW on post-ICU mortality was analyzed using a multivariable Cox proportional hazards model. The independent effect of ICU-AW on the PF domain score was analyzed using a multivariable linear regression model. Results: 156 patients were included, of whom 80 with ICU-AW. Twenty-three patients died in the ICU (20 with ICU-AW); during the 6 months follow-up after ICU discharge another 25 patients died (17 with ICU-AW). PF scores were available for 96 survivors (39 patients with ICU-AW). ICU-AW was independently associated with an increase in post-ICU mortality (HR 3.6 (95% CI: 1.3 to 9.8); p:0.01) and with a decrease in physical functioning (β: -16.7 points (95% CI: -30.2 to -3.1); p:0.02). Conclusion: ICU-AW is independently associated with higher post-ICU mortality and with clinically relevant lower physical functioning in survivors at 6 months after ICU discharge.
Early deep sedation is associated with decreased in-hospital and two-years follow-up survival
Early deep sedation is associated with decreased in-hospital and two-years follow-up survival. Critical Care 2015, 19: 197
Balzer, F., et al.
http://ccforum.com/content/pdf/s13054-015-0929-2.pdf
There is increasing evidence that deep sedation is detrimental to critically ill patients. The aim of this study was to examine effects of deep sedation during the early period after ICU admission on short- and long-term survival. Methods: In this observational, matched-pair analysis, patients with mechanical ventilation that were admitted to ICUs of a tertiary university hospital in six consecutive years were grouped as either lightly or deeply sedated within the first 48 hours after ICU admission. The Richmond-Agitation and Sedation Score (RASS) was used to assess sedation depth (light sedation: −2 to 0; deep: −3 or below). Multivariate Cox regression was conducted to investigate the impact of early deep sedation within the first 48 hours of admission on in-hospital and two-years follow-up survival. Results: In total, 1,884 patients met inclusion criteria out of which 27.2% (n = 513) were deeply sedated. Deeply sedated patients had longer ventilation times, increased length of stay and higher rates of mortality. Early deep sedation was associated with a hazard ratio of 1.661 (95% CI: 1.074-2.567; p = 0.022) for in-hospital survival and 1.866 (95% CI: 1.351-2.576; p < 0.001) for two-years follow-up survival. Conclusions: Early deep sedation during the first 48 hours of intensive care treatment was associated with decreased in-hospital and two-years follow-up survival. Since early deep sedation is a modifiable risk factor, this data shows an urgent need for prospective clinical trials focusing on light sedation in the early phase of ICU treatment.
Balzer, F., et al.
http://ccforum.com/content/pdf/s13054-015-0929-2.pdf
There is increasing evidence that deep sedation is detrimental to critically ill patients. The aim of this study was to examine effects of deep sedation during the early period after ICU admission on short- and long-term survival. Methods: In this observational, matched-pair analysis, patients with mechanical ventilation that were admitted to ICUs of a tertiary university hospital in six consecutive years were grouped as either lightly or deeply sedated within the first 48 hours after ICU admission. The Richmond-Agitation and Sedation Score (RASS) was used to assess sedation depth (light sedation: −2 to 0; deep: −3 or below). Multivariate Cox regression was conducted to investigate the impact of early deep sedation within the first 48 hours of admission on in-hospital and two-years follow-up survival. Results: In total, 1,884 patients met inclusion criteria out of which 27.2% (n = 513) were deeply sedated. Deeply sedated patients had longer ventilation times, increased length of stay and higher rates of mortality. Early deep sedation was associated with a hazard ratio of 1.661 (95% CI: 1.074-2.567; p = 0.022) for in-hospital survival and 1.866 (95% CI: 1.351-2.576; p < 0.001) for two-years follow-up survival. Conclusions: Early deep sedation during the first 48 hours of intensive care treatment was associated with decreased in-hospital and two-years follow-up survival. Since early deep sedation is a modifiable risk factor, this data shows an urgent need for prospective clinical trials focusing on light sedation in the early phase of ICU treatment.
Clinical impact of stress dose steroids in patients with septic shock
Clinical impact of stress dose steroids in patients with septic shock: Insights from the PROWESS-Shock trial. Critical Care, 2015, 19: 193
Povoa, P., et al.
http://ccforum.com/content/pdf/s13054-015-0921-x.pdf
The aim of our study was to evaluate the clinical impact of the administration of intravenous steroids, alone or in conjunction with drotrecogin-alfa (activated) (DrotAA), on the outcomes in septic shock patients. Methods: We performed a sub-study of the PROWESS-Shock trial (septic shock patients who received fluids and vasopressors above a predefined threshold for at least 4 hours were randomized to receive either DrotAA or placebo for 96 hours). A propensity score for the administration of intravenous steroids for septic shock at baseline was constructed using multivariable logistic regression. Cox proportional hazards model using inverse probability of treatment weighting of the propensity score was used to estimate the effect of intravenous steroids, alone or in conjunction with DrotAA, on 28-day and 90-day all-cause mortality. Results: A total of 1695 patients were enrolled of which 49.5% received intravenous steroids for treatment of septic shock at baseline (DrotAA + steroids N = 436; DrotAA + no steroids N = 414; placebo + steroids N = 403; placebo + no steroids N = 442). The propensity weighted risk of 28-day as well as 90-day mortality in those treated vs. those not treated with steroids did not differ among those randomized to DrotAA vs. placebo (interaction p-value = 0.38 and p = 0.27, respectively) nor was a difference detected within each randomized treatment. Similarly, the course of vasopressor use and cardiovascular SOFA did not appear to be influenced by steroid therapy. In patients with lung infection (N = 744), abdominal infection (N = 510), Gram-positive sepsis (N = 420) and Gram-negative sepsis (N = 461), the propensity weighted risk of 28-day as well as 90-day mortality in those treated vs. those not treated with steroids did not differ among those randomized to DrotAA vs. placebo (interaction 28-day, p = 0.65, p = 0.58, p = 0.49, p = 0.12; 90-day, p = 0.75, p = 0.56, p = 0.18, p = 0.12, respectively) nor was a difference detected within each randomized treatment. Conclusions: In the present study of septic shock patients, after adjustment for treatment selection bias, we were unable to find noticeable positive impact from intravenous steroids for treatment of septic shock at baseline either in patients randomized for DrotAA or placebo.
Povoa, P., et al.
http://ccforum.com/content/pdf/s13054-015-0921-x.pdf
The aim of our study was to evaluate the clinical impact of the administration of intravenous steroids, alone or in conjunction with drotrecogin-alfa (activated) (DrotAA), on the outcomes in septic shock patients. Methods: We performed a sub-study of the PROWESS-Shock trial (septic shock patients who received fluids and vasopressors above a predefined threshold for at least 4 hours were randomized to receive either DrotAA or placebo for 96 hours). A propensity score for the administration of intravenous steroids for septic shock at baseline was constructed using multivariable logistic regression. Cox proportional hazards model using inverse probability of treatment weighting of the propensity score was used to estimate the effect of intravenous steroids, alone or in conjunction with DrotAA, on 28-day and 90-day all-cause mortality. Results: A total of 1695 patients were enrolled of which 49.5% received intravenous steroids for treatment of septic shock at baseline (DrotAA + steroids N = 436; DrotAA + no steroids N = 414; placebo + steroids N = 403; placebo + no steroids N = 442). The propensity weighted risk of 28-day as well as 90-day mortality in those treated vs. those not treated with steroids did not differ among those randomized to DrotAA vs. placebo (interaction p-value = 0.38 and p = 0.27, respectively) nor was a difference detected within each randomized treatment. Similarly, the course of vasopressor use and cardiovascular SOFA did not appear to be influenced by steroid therapy. In patients with lung infection (N = 744), abdominal infection (N = 510), Gram-positive sepsis (N = 420) and Gram-negative sepsis (N = 461), the propensity weighted risk of 28-day as well as 90-day mortality in those treated vs. those not treated with steroids did not differ among those randomized to DrotAA vs. placebo (interaction 28-day, p = 0.65, p = 0.58, p = 0.49, p = 0.12; 90-day, p = 0.75, p = 0.56, p = 0.18, p = 0.12, respectively) nor was a difference detected within each randomized treatment. Conclusions: In the present study of septic shock patients, after adjustment for treatment selection bias, we were unable to find noticeable positive impact from intravenous steroids for treatment of septic shock at baseline either in patients randomized for DrotAA or placebo.
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