Impact of Initial Ventilatory Strategy in Hematological Patients With Acute Respiratory Failure: A Systematic Review and Meta-Analysis

Impact of Initial Ventilatory Strategy in Hematological Patients With Acute Respiratory Failure: A Systematic Review and Meta-Analysis

Critical Care Medicine: July 2016 - Volume 44 - Issue 7 - p 1406–1413

Amado-Rodríguez, L


Objective: Acute respiratory failure in hematological patients is related to a high mortality. Noninvasive mechanical ventilation may benefit a subset of these patients, but the overall effect on mortality and the risks derived from its failure are unclear. Our objective was to review the impact of initial ventilatory strategy on mortality and the risks related to noninvasive mechanical ventilation failure in this group of patients. Data Sources: Data sources, including PubMed and conference proceedings, were searched from the year 2000 to January 2015. Study Selection: We selected studies reporting mortality and the need for mechanical ventilation in hematological patients with acute respiratory failure. Data Extraction: Two trained reviewers independently conducted study selection, abstracted data, and assessed the risk of bias. Discrepancies between reviewers were resolved through discussion and consensus. The outcomes explored were all-cause mortality after mechanical ventilation and incidence of noninvasive mechanical ventilation failure. Data Synthesis: A random-effects model was used in all the analysis. Thirteen studies, involving 2,380 patients, were included. Use of noninvasive mechanical ventilation was related to a better outcome than initial intubation (risk ratio, 0.74; 95% CI, 0.65–0.84). Failure of noninvasive mechanical ventilation did not increase the overall risk of death (risk ratio, 1.02; 95% CI, 0.93–1.13). There were signs of publication bias and substantial heterogeneity among the studies. Compensation of this bias by using the trim-and-fill method showed a significant risk of death after noninvasive mechanical ventilation failure (risk ratio, 1.07; 95% CI, 1.00–1.14). Meta-regression analysis showed that the predicted risk of death for the noninvasive mechanical ventilation group acted as a significant moderator, with a higher risk of death after noninvasive mechanical ventilation failure in those studies reporting lower predicted mortality. Conclusions: Noninvasive mechanical ventilation is associated with a lower risk of death in hematological patients with respiratory failure. Noninvasive mechanical ventilation failure may worsen the prognosis, mainly in less severe patients.

Outcome Measurement in ICU Survivorship Research From 1970 to 2013: A Scoping Review of 425 Publications

Outcome Measurement in ICU Survivorship Research From 1970 to 2013: A Scoping Review of 425 Publications

Critical Care Medicine: July 2016 - Volume 44 - Issue 7 - p 1267–1277

Turnbull, A et al



Objectives: To evaluate the study designs and measurement instruments used to assess physical, cognitive, mental health, and quality of life outcomes of survivors of critical illness over more than 40 years old as a first step toward developing a core outcome set of measures for future trials to improve outcomes in ICU survivors. Design: Scoping review. Setting: Published articles that included greater than or equal to one postdischarge measure of a physical, cognitive, mental health, or quality of life outcome in more than or equal to 20 survivors of critical illness published between 1970 and 2013. Instruments were classified using the World Health Organization’s International Classification of Functioning, Disability, and Health framework. Subjects: ICU survivors. Interventions: None. Measurements and Main Results: We reviewed 15,464 abstracts, and identified 425 eligible articles, including 31 randomized trials (7%), 116 cross-sectional studies (27%), and 278 cohort studies (65%). Cohort studies had a median (interquartile range) sample size of 96 survivors (52–209), with 38% not fully reporting loss to follow-up. A total of 250 different measurement instruments were used in these 425 articles. Among eligible articles, 25 measured physical activity limitations (6%), 40 measured cognitive activity limitations (9%), 114 measured mental health impairment (27%), 196 measured participation restriction (46%), and 276 measured quality of life (65%). Conclusions: Peer-reviewed publications reporting patient outcomes after hospital discharge for ICU survivors have grown from 3 in the 1970s to more than 300 since 2000. Although there is evidence of consolidation in the instruments used for measuring participation restriction and quality of life, the ability to compare results across studies remains impaired by the 250 different instruments used. Most articles described cohort studies of modest size with a single follow-up assessment using patient-reported measures of participation restriction and quality of life. Development of a core outcome set of valid, reliable, and feasible measures is essential to improving the outcomes of critical illness survivors.

An Official Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Healthcare Professionals: A Call for Action

An Official Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Healthcare Professionals: A Call for Action

Critical Care Medicine: July 2016 - Volume 44 - Issue 7 - p 1414–1421
Moss, M et al



Burnout syndrome (BOS) occurs in all types of healthcare professionals and is especially common in individuals who care for critically ill patients. The development of BOS is related to an imbalance of personal characteristics of the employee and work-related issues or other organizational factors. BOS is associated with many deleterious consequences, including increased rates of job turnover, reduced patient satisfaction, and decreased quality of care. BOS also directly affects the mental health and physical well-being of the many critical care physicians, nurses, and other healthcare professionals who practice worldwide. Until recently, BOS and other psychological disorders in critical care healthcare professionals remained relatively unrecognized. To raise awareness of BOS, the Critical Care Societies Collaborative (CCSC) developed this call to action. The present article reviews the diagnostic criteria, prevalence, causative factors, and consequences of BOS. It also discusses potential interventions that may be used to prevent and treat BOS. Finally, we urge multiple stakeholders to help mitigate the development of BOS in critical care healthcare professionals and diminish the harmful consequences of BOS, both for critical care healthcare professionals and for patients.

Mechanical Ventilation and Diaphragmatic Atrophy in Critically Ill Patients: An Ultrasound Study

Mechanical Ventilation and Diaphragmatic Atrophy in Critically Ill Patients: An Ultrasound Study

Critical Care Medicine: July 2016 - Volume 44 - Issue 7 - p 1347–1352

Zambon, M et al

Objective: Mechanical ventilation contributes to diaphragmatic atrophy and dysfunction, and few techniques exist to assess diaphragmatic function: the purpose of this study was to quantify diaphragm atrophy in a population of critically ill mechanically ventilated patients with ultrasound and to identify risk factors that can worsen diaphragmatic activity. Design: Prospective observational study. Setting: ICU of a 1,200-bed university hospital. Patients: Newly intubated adult critically ill patients. Interventions: Diaphragm thickness in the zone of apposition was measured daily with ultrasound, from the first day of mechanical ventilation till discharge to the main ward. Measurements and Main Results: Daily atrophy rate (ΔTdi/d) was calculated as the reduction in percentage from the previous measurement. To analyze the difference in atrophy rate (ΔTdi/d), ventilation was categorized into four classes: spontaneous breathing or continuous positive airway pressure; pressure support ventilation 5–12 cm H2O (low pressure support ventilation); pressure support ventilation greater than 12 cm H2O (high pressure support ventilation); and controlled mechanical ventilation. Multivariate analysis with ventilation support and other clinical variables was performed to identify risk factors for atrophy. Forty patients underwent a total of 153 ultrasonographic evaluations. Mean (SD) ΔTdi/d was –7.5% (12.3) during controlled mechanical ventilation, –5.3% (12.9) at high pressure support ventilation, –1.5% (10.9) at low pressure support ventilation, +2.3% (9.5) during spontaneous breathing or continuous positive airway pressure. At multivariate analysis, only the ventilation support was predictive of diaphragm atrophy rate. Pressure support predicted diaphragm thickness with coefficient –0.006 (95% CI, –0.010 to –0.002; p = 0.006). Conclusions: In critically ill mechanically ventilated patients, there is a linear relationship between ventilator support and diaphragmatic atrophy rate.

How Long Does (S)He Have? Retrospective Analysis of Outcomes After Palliative Extubation in Elderly, Chronically Critically Ill Patients

How LongDoes (S)He Have? Retrospective Analysis of Outcomes After Palliative Extubation in Elderly, Chronically Critically Ill Patients

Critical Care Medicine: June 2016 - Volume 44 - Issue 6 - p 1138–1144

Pan, CX et al

Objective: For chronically critically ill elderly patients on mechanical ventilation, prognosis for significant recovery may be minimal. These individuals, or their surrogates, may decide for “palliative extubation.” A common prognostic question arises: “How long does she/he have?” This study describes demographics, mortality, time to death, and factors associated with death after palliative extubation. Design, Setting, and Patients: Retrospective 3-year study in community hospital with ethnically diverse elderly population. Chronically critically ill patients followed from palliative extubation to death or survival to discharge. Measures: Mortality/survival following palliative extubation, time to death or discharge, factors associated with death. Results: Hundred and forty-eight subjects underwent palliative extubation. Mean age: 78 years, 60% female, ethnically diverse with 46% white, and 54% others. Top diagnostic categories: sepsis (47%) and respiratory failure (22%). After extubation, 114 patients (77%) died in hospital and 34 (23%) were discharged. Of those who died, median time to death 8.9 hours (range, 4 min to 7 d). Mortality proportion was 56% at 24 hours and increased with time. Factors associated with early death: Systolic blood pressure less than 90 (p = 0.002) and Charlson Comorbidity Index that is above 6 or 0 (p = 0.002). Conclusions: Palliative extubation at end of life was an option selected by an ethnically diverse elderly population. Approximately three-fourths of subjects died in hospital, and one-fourth was discharged alive. Over 50% who died did so within 24 hours, making this useful information for counseling and anticipatory planning. Subjects with systolic blood pressure less than 90 and Charlson Comorbidity Index that is very low or very high had higher mortality.

Impact of Proactive Nurse Participation in ICU Family Conferences: A Mixed-Method Study

Impact of Proactive Nurse Participation in ICU Family Conferences: A Mixed-Method Study

Critical Care Medicine: June 2016 - Volume 44 - Issue 6 - p 1116–1128

Garrouste-Orgeas, M et al

Objectives: To investigate family perceptions of having a nurse participating in family conferences and to assess the psychologic well being of the same families after ICU discharge. Design: Mixed-method design with a qualitative study embedded in a single-center randomized study. Setting: Twelve-bed medical-surgical ICU in a 460-bed tertiary hospital. Subjects: One family member for each consecutive patient who received more than 48 hours of mechanical ventilation in the ICU. Intervention: Planned proactive participation of a nurse in family conferences led by a physician. In the control group, conferences were led by a physician without a nurse. Measurements and Main Results: Of the 172 eligible family members, 100 (60.2%) were randomized; among them, 88 underwent semistructured interviews at ICU discharge and 86 completed the Peritraumatic Dissociative Experiences Questionnaire at ICU discharge and then the Hospital Anxiety Depression Questionnaire and the Impact of Event Scale (for posttraumatic stress–related symptoms) 3 months later. The intervention and control groups were not significantly different regarding the prevalence of posttraumatic stress–related symptoms (52.3 vs 50%, respectively; p = 0.83). Anxiety and depression subscale scores were significantly lower in the intervention group. The qualitative data indicated that the families valued the principle of the conference itself. Perceptions of nurse participation clustered into four main themes: trust that ICU teamwork was effective (50/88; 56.8%), trust that care was centered on the patient (33/88; 37.5%), trust in effective dissemination of information (15/88; 17%), and trust that every effort was made to relieve anxiety in family members (12/88; 13.6%). Conclusions: Families valued the conferences themselves and valued the proactive participation of a nurse. These positive perceptions were associated with significant anxiety or depression subscale scores but not with changes in posttraumatic stress–related symptoms.