Overtreatment of Heparin-Induced Thrombocytopenia in the Surgical ICU
Critical Care Medicine:January 2017 - Volume 45 - Issue 1 - p 28–34
Harada, M et al
Objective: Recent studies reveal a high occurrence of overdiagnosis of heparin-induced thrombocytopenia in surgical patients with critical illness. The optimal criteria for diagnosis of heparin-induced thrombocytopenia remain unclear, contributing to unnecessary treatment. We reviewed patients who were admitted to surgical ICUs and were suspected of heparin-induced thrombocytopenia to identify how often patients were correctly treated.
Design: In this clinical prospective study, data were collected including age, sex, antiplatelet factor 4/heparin enzyme-linked immunosorbent assay, serotonin release assay, and Warkentin 4Ts scores. Heparin-induced thrombocytopenia-positive patients were defined as those with both positive antiplatelet factor 4/heparin enzyme-linked immunosorbent assay (optical density, ≥ 0.40) and positive serotonin release assay results.
Setting: Urban tertiary medical center. Patients: Patients admitted to the surgical and cardiac ICU who were presumed to have heparin-induced thrombocytopenia and underwent antiplatelet factor 4/heparin enzyme-linked immunosorbent assay and serotonin release assay testing between January 1, 2011, and August 1, 2014. Interventions: None.
Measurements and Main Results: A total of 135 patients had 4Ts, antiplatelet factor 4/heparin enzyme-linked immunosorbent assay, and serotonin release assay scores. A total of 11 patients (8.1%) had positive serotonin release assay and 80 patients had positive antiplatelet factor 4/heparin enzyme-linked immunosorbent assay; 10 patients were identified as heparin-induced thrombocytopenia positive. Positive serotonin release assay was noted in nine of 11 patients (81.8%) with antiplatelet factor 4/heparin enzyme-linked immunosorbent assay optical density greater than or equal to 2.0, compared with one of 22 patients (4.5%) with optical density values of 0.85–1.99, and one of 102 patients (1.0%) with optical density values of 0–0.84. Out of 135 patients, 29 patients (21.5%) received treatment with argatroban, lepirudin, or fondaparinux: 10 of 10 heparin-induced thrombocytopenia-positive patients (100%) compared with 19 of 125 heparin-induced thrombocytopenia-negative patients (15%).
Conclusions: Overtreatment of heparin-induced thrombocytopenia in the surgical ICU continues even with recent increased caution encouraging a higher antiplatelet factor 4/heparin enzyme-linked immunosorbent assay optical density threshold before initiating treatment. More stringent criteria should be used to determine when to order serologic testing and when the results of such testing should prompt a change in anticoagulant treatment. If antiplatelet factor 4/heparin enzyme-linked immunosorbent assay is used to consider immediate treatment, an optical density greater than or equal to 2.0 may be a more appropriate threshold.
Tuesday, 17 January 2017
Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU
Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU
Critical Care Medicine:January 2017 - Volume 45 - Issue 1 - p 103–128
Davidson, J et al
Objective: To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU. Methods: We used the Council of Medical Specialty Societies principles for the development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU.
We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with the guideline development.
Results: The scoping review yielded 683 qualitative studies; 228 were used for thematic analysis and Population, Intervention, Comparison, Outcome question development. The systematic review search yielded 4,158 reports after deduplication and 76 additional studies were added from alerts and hand searches; 238 studies met inclusion criteria. We made 23 recommendations from moderate, low, and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice.
Conclusions: These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.
Critical Care Medicine:January 2017 - Volume 45 - Issue 1 - p 103–128
Davidson, J et al
Objective: To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU. Methods: We used the Council of Medical Specialty Societies principles for the development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU.
We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with the guideline development.
Results: The scoping review yielded 683 qualitative studies; 228 were used for thematic analysis and Population, Intervention, Comparison, Outcome question development. The systematic review search yielded 4,158 reports after deduplication and 76 additional studies were added from alerts and hand searches; 238 studies met inclusion criteria. We made 23 recommendations from moderate, low, and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice.
Conclusions: These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.
Lung Injury Prediction Score in Hospitalized Patients at Risk of Acute Respiratory Distress Syndrome
Lung Injury Prediction Score in Hospitalized Patients at Risk of Acute Respiratory Distress Syndrome
Critical Care Medicine:December 2016 - Volume 44 - Issue 12 - p 2182–2191
Soto, G et al
Objective: The Lung Injury Prediction Score identifies patients at risk for acute respiratory distress syndrome in the emergency department, but it has not been validated in non-emergency department hospitalized patients. We aimed to evaluate whether Lung Injury Prediction Score identifies non-emergency department hospitalized patients at risk of developing acute respiratory distress syndrome at the time of critical care contact.
Design: Retrospective study. Setting: Five academic medical centers. Patients: Nine hundred consecutive patients (≥ 18 yr old) with at least one acute respiratory distress syndrome risk factor at the time of critical care contact. Interventions: None.
Measurements and Main Results: Lung Injury Prediction Score was calculated using the worst values within the 12 hours before initial critical care contact. Patients with acute respiratory distress syndrome at the time of initial contact were excluded. Acute respiratory distress syndrome developed in 124 patients (13.7%) a median of 2 days (interquartile range, 2–3) after critical care contact. Hospital mortality was 22% and was significantly higher in acute respiratory distress syndrome than non-acute respiratory distress syndrome patients (48% vs 18%; p < 0.001). Increasing Lung Injury Prediction Score was significantly associated with development of acute respiratory distress syndrome (odds ratio, 1.31; 95% CI, 1.21–1.42) and the composite outcome of acute respiratory distress syndrome or death (odds ratio, 1.26; 95% CI, 1.18–1.34). A Lung Injury Prediction Score greater than or equal to 4 was associated with the development of acute respiratory distress syndrome (odds ratio, 4.17; 95% CI, 2.26–7.72), composite outcome of acute respiratory distress syndrome or death (odds ratio, 2.43; 95% CI, 1.68–3.49), and acute respiratory distress syndrome after accounting for the competing risk of death (hazard ratio, 3.71; 95% CI, 2.05–6.72). For acute respiratory distress syndrome development, the Lung Injury Prediction Score has an area under the receiver operating characteristic curve of 0.70 and a Lung Injury Prediction Score greater than or equal to 4 has 90% sensitivity (misses only 10% of acute respiratory distress syndrome cases), 31% specificity, 17% positive predictive value, and 95% negative predictive value. Conclusions: In a cohort of non-emergency department hospitalized patients, the Lung Injury Prediction Score and Lung Injury Prediction Score greater than or equal to 4 can identify patients at increased risk of acute respiratory distress syndrome and/or death at the time of critical care contact but it does not perform as well as in the original emergency department cohort.
Critical Care Medicine:December 2016 - Volume 44 - Issue 12 - p 2182–2191
Soto, G et al
Objective: The Lung Injury Prediction Score identifies patients at risk for acute respiratory distress syndrome in the emergency department, but it has not been validated in non-emergency department hospitalized patients. We aimed to evaluate whether Lung Injury Prediction Score identifies non-emergency department hospitalized patients at risk of developing acute respiratory distress syndrome at the time of critical care contact.
Design: Retrospective study. Setting: Five academic medical centers. Patients: Nine hundred consecutive patients (≥ 18 yr old) with at least one acute respiratory distress syndrome risk factor at the time of critical care contact. Interventions: None.
Measurements and Main Results: Lung Injury Prediction Score was calculated using the worst values within the 12 hours before initial critical care contact. Patients with acute respiratory distress syndrome at the time of initial contact were excluded. Acute respiratory distress syndrome developed in 124 patients (13.7%) a median of 2 days (interquartile range, 2–3) after critical care contact. Hospital mortality was 22% and was significantly higher in acute respiratory distress syndrome than non-acute respiratory distress syndrome patients (48% vs 18%; p < 0.001). Increasing Lung Injury Prediction Score was significantly associated with development of acute respiratory distress syndrome (odds ratio, 1.31; 95% CI, 1.21–1.42) and the composite outcome of acute respiratory distress syndrome or death (odds ratio, 1.26; 95% CI, 1.18–1.34). A Lung Injury Prediction Score greater than or equal to 4 was associated with the development of acute respiratory distress syndrome (odds ratio, 4.17; 95% CI, 2.26–7.72), composite outcome of acute respiratory distress syndrome or death (odds ratio, 2.43; 95% CI, 1.68–3.49), and acute respiratory distress syndrome after accounting for the competing risk of death (hazard ratio, 3.71; 95% CI, 2.05–6.72). For acute respiratory distress syndrome development, the Lung Injury Prediction Score has an area under the receiver operating characteristic curve of 0.70 and a Lung Injury Prediction Score greater than or equal to 4 has 90% sensitivity (misses only 10% of acute respiratory distress syndrome cases), 31% specificity, 17% positive predictive value, and 95% negative predictive value. Conclusions: In a cohort of non-emergency department hospitalized patients, the Lung Injury Prediction Score and Lung Injury Prediction Score greater than or equal to 4 can identify patients at increased risk of acute respiratory distress syndrome and/or death at the time of critical care contact but it does not perform as well as in the original emergency department cohort.
Protocol-Based Resuscitation Bundle to Improve Outcomes in Septic Shock Patients: Evaluation of the Michigan Health and Hospital Association Keystone Sepsis Collaborative
Protocol-Based Resuscitation Bundle to Improve Outcomes in Septic Shock Patients: Evaluation of the Michigan Health and Hospital Association Keystone Sepsis Collaborative
Critical Care Medicine: December 2016 - Volume 44 - Issue 12 - p 2123–2130
Thompson, M et al
Objectives: To evaluate the impact of a multi-ICU quality improvement collaborative implementing a protocol-based resuscitation bundle to treat septic shock patients.
Design: A difference-in-differences analysis compared patient outcomes in hospitals participating in the Michigan Health & Hospital Association Keystone Sepsis collaborative (n = 37) with noncollaborative hospitals (n = 50) pre- (2010–2011) and postimplementation (2012–2013). Collaborative hospitals were also stratified as high (n = 19) and low (n = 18) adherence based on their overall bundle adherence.
Setting: Eighty-seven Michigan hospitals with ICUs. Patients: We compared 22,319 septic shock patients in collaborative hospitals compared to 26,055 patients in noncollaborative hospitals using the Michigan Inpatient Database. Interventions: Multidisciplinary ICU teams received informational toolkits, standardized screening tools, and continuous quality improvement, aided by cultural improvement.
Measurements and Main Results: In-hospital mortality and hospital length of stay significantly improved between pre- and postimplementation periods for both collaborative and noncollaborative hospitals. Comparing collaborative and noncollaborative hospitals, we found no additional reductions in mortality (odds ratio, 0.94; 95% CI, 0.87–1.01; p = 0.106) or length of stay (–0.3 d; 95% CI, –0.7 to 0.1 d; p = 0.174). Compared to noncollaborative hospitals, high adherence hospitals had significant reductions in mortality (odds ratio, 0.84; 95% CI, 0.79–0.93; p < 0.001) and length of stay (–0.7 d; 95% CI, –1.1 to –0.2; p < 0.001), whereas low adherence hospitals did not (odds ratio, 1.07; 95% CI, 0.97–1.19; p = 0.197; 0.2 d; 95% CI, –0.3 to 0.8; p = 0.367). Conclusions: Participation in the Keystone Sepsis collaborative was unable to improve patient outcomes beyond concurrent trends. High bundle adherence hospitals had significantly greater improvements in outcomes, but further work is needed to understand these findings.
Critical Care Medicine: December 2016 - Volume 44 - Issue 12 - p 2123–2130
Thompson, M et al
Objectives: To evaluate the impact of a multi-ICU quality improvement collaborative implementing a protocol-based resuscitation bundle to treat septic shock patients.
Design: A difference-in-differences analysis compared patient outcomes in hospitals participating in the Michigan Health & Hospital Association Keystone Sepsis collaborative (n = 37) with noncollaborative hospitals (n = 50) pre- (2010–2011) and postimplementation (2012–2013). Collaborative hospitals were also stratified as high (n = 19) and low (n = 18) adherence based on their overall bundle adherence.
Setting: Eighty-seven Michigan hospitals with ICUs. Patients: We compared 22,319 septic shock patients in collaborative hospitals compared to 26,055 patients in noncollaborative hospitals using the Michigan Inpatient Database. Interventions: Multidisciplinary ICU teams received informational toolkits, standardized screening tools, and continuous quality improvement, aided by cultural improvement.
Measurements and Main Results: In-hospital mortality and hospital length of stay significantly improved between pre- and postimplementation periods for both collaborative and noncollaborative hospitals. Comparing collaborative and noncollaborative hospitals, we found no additional reductions in mortality (odds ratio, 0.94; 95% CI, 0.87–1.01; p = 0.106) or length of stay (–0.3 d; 95% CI, –0.7 to 0.1 d; p = 0.174). Compared to noncollaborative hospitals, high adherence hospitals had significant reductions in mortality (odds ratio, 0.84; 95% CI, 0.79–0.93; p < 0.001) and length of stay (–0.7 d; 95% CI, –1.1 to –0.2; p < 0.001), whereas low adherence hospitals did not (odds ratio, 1.07; 95% CI, 0.97–1.19; p = 0.197; 0.2 d; 95% CI, –0.3 to 0.8; p = 0.367). Conclusions: Participation in the Keystone Sepsis collaborative was unable to improve patient outcomes beyond concurrent trends. High bundle adherence hospitals had significantly greater improvements in outcomes, but further work is needed to understand these findings.
Long-Term Survival Rate in Patients With Acute Respiratory Failure Treated With Noninvasive Ventilation in Ordinary Wards
Long-Term Survival Rate in Patients With Acute Respiratory Failure Treated With Noninvasive Ventilation in Ordinary Wards
Critical Care Medicine: December 2016 - Volume 44 - Issue 12 - p 2139–2144
Cabrini, L et al
Objective: Noninvasive ventilation is a life-saving technique increasingly used to treat acute respiratory failure. Noninvasive ventilation has been applied mostly in ICUs, but several reasons brought to an increasing application of noninvasive ventilation in ordinary wards. Few articles evaluated the outcomes of patients receiving noninvasive ventilation including long-term follow-up. The aim of the present study was to assess 1-year survival rate of patients treated with noninvasive ventilation outside the ICU for acute respiratory failure of heterogeneous causes and to identify the predictors of long-term mortality.
Design: Prospective, observational, pragmatic study. Setting: Ordinary wards of a teaching hospital. Patients: Consecutive patients treated with noninvasive ventilation for acute respiratory failure. Interventions: None.
Measurements and Main Results: Two-hundred and twenty-patients were enrolled. Mortality rates at 30-day, 90-days, and 1-year follow-up were 20%, 26%, and 34%. When excluding patients with “do-not-resuscitate” status, mortality rates were 13%, 19%, and 28%. The multivariate analyses identified solid cancer, pneumonia in hematologic patients, and do-not-resuscitate status as independent predictors of mortality with postoperative acute respiratory failure associated with improved survival. The same predictors were confirmed when excluding do-not-resuscitate patients from the analyses. Conclusions: Noninvasive ventilation applied in ordinary wards was effective, with long-term outcomes not different from those reported for ICU settings. Solid cancer, pneumonia in hematologic malignancies, and do-not-resuscitate status predicted mortality, whereas patients with postoperative acute respiratory failure had the best survival rate. Additional studies are required to evaluate noninvasive ventilation efficacy in the wards compared with ICU.
Critical Care Medicine: December 2016 - Volume 44 - Issue 12 - p 2139–2144
Cabrini, L et al
Objective: Noninvasive ventilation is a life-saving technique increasingly used to treat acute respiratory failure. Noninvasive ventilation has been applied mostly in ICUs, but several reasons brought to an increasing application of noninvasive ventilation in ordinary wards. Few articles evaluated the outcomes of patients receiving noninvasive ventilation including long-term follow-up. The aim of the present study was to assess 1-year survival rate of patients treated with noninvasive ventilation outside the ICU for acute respiratory failure of heterogeneous causes and to identify the predictors of long-term mortality.
Design: Prospective, observational, pragmatic study. Setting: Ordinary wards of a teaching hospital. Patients: Consecutive patients treated with noninvasive ventilation for acute respiratory failure. Interventions: None.
Measurements and Main Results: Two-hundred and twenty-patients were enrolled. Mortality rates at 30-day, 90-days, and 1-year follow-up were 20%, 26%, and 34%. When excluding patients with “do-not-resuscitate” status, mortality rates were 13%, 19%, and 28%. The multivariate analyses identified solid cancer, pneumonia in hematologic patients, and do-not-resuscitate status as independent predictors of mortality with postoperative acute respiratory failure associated with improved survival. The same predictors were confirmed when excluding do-not-resuscitate patients from the analyses. Conclusions: Noninvasive ventilation applied in ordinary wards was effective, with long-term outcomes not different from those reported for ICU settings. Solid cancer, pneumonia in hematologic malignancies, and do-not-resuscitate status predicted mortality, whereas patients with postoperative acute respiratory failure had the best survival rate. Additional studies are required to evaluate noninvasive ventilation efficacy in the wards compared with ICU.
Bone Failure in Critical Illness
Bone Failure in Critical Illness
Critical Care Medicine: December 2016 - Volume 44 - Issue 12 - p 2270–2274
Lee, P
Objectives: The origin of systemic inflammatory response syndrome and multiple organ dysfunction syndrome is poorly understood but remains a fundamental concern in the ICU.
This paper provides a critical appraisal on whether bone failure may represent an unrecognized component of systemic inflammatory response syndrome/multiple organ dysfunction syndrome.
Data Sources, Data Selection, and Data Extraction: Search of the PubMed database and manual review of selected articles investigating bone pathophysiology in critical illness.
Data Synthesis: Bone hyperresorption is highly prevalent among critically ill patients. Bone breakdown releases numerous systemically active cytokines and bone-sequestered toxins, with the capacity to fuel inflammatory hypercytokinaemia and metabolic toxaemia. Anti-resorptive medication inhibits bone break down and preadmission anti-resorptive use is associated with superior survival among critically ill patients.
Conclusions: We propose that hyperresorptive bone failure is an unrecognised component of systemic inflammatory response syndrome/multiple organ dysfunction syndrome that is causal to critical illness progression. If this hypothesis is valid, bone preservative strategies could reduce the risk of osteoporosis/fractures among ICU survivors, as well as decreasing critical illness mortality.
Critical Care Medicine: December 2016 - Volume 44 - Issue 12 - p 2270–2274
Lee, P
Objectives: The origin of systemic inflammatory response syndrome and multiple organ dysfunction syndrome is poorly understood but remains a fundamental concern in the ICU.
This paper provides a critical appraisal on whether bone failure may represent an unrecognized component of systemic inflammatory response syndrome/multiple organ dysfunction syndrome.
Data Sources, Data Selection, and Data Extraction: Search of the PubMed database and manual review of selected articles investigating bone pathophysiology in critical illness.
Data Synthesis: Bone hyperresorption is highly prevalent among critically ill patients. Bone breakdown releases numerous systemically active cytokines and bone-sequestered toxins, with the capacity to fuel inflammatory hypercytokinaemia and metabolic toxaemia. Anti-resorptive medication inhibits bone break down and preadmission anti-resorptive use is associated with superior survival among critically ill patients.
Conclusions: We propose that hyperresorptive bone failure is an unrecognised component of systemic inflammatory response syndrome/multiple organ dysfunction syndrome that is causal to critical illness progression. If this hypothesis is valid, bone preservative strategies could reduce the risk of osteoporosis/fractures among ICU survivors, as well as decreasing critical illness mortality.
Thursday, 17 November 2016
Tissue interface pressure and skin integrity in critically ill, mechanically ventilated patients
Tissue interface pressure and skin integrity in critically ill, mechanically ventilated patients
Grap, MJ et al
Intensive and Critical Care Nursing- Article in Press
To describe tissue interface pressure, time spent above critical pressure levels and the effect on skin integrity at seven anatomical locations.
Objective
To describe tissue interface pressure, time spent above critical pressure levels and the effect on skin integrity at seven anatomical locations.
Design, setting, patients
Descriptive, longitudinal study in critically ill mechanically ventilated adults, from Surgical Trauma ICU-STICU; Medical Respiratory ICU-MRICU; Neuroscience ICU-NSICU in a Mid-Atlantic urban university medical centre. Subjects were enroled in the study within 24 hours of intubation.
Measurements
Tissue interface pressure was measured continuously using the XSENSOR pressure mapping system (XSENSOR Technology Corporation, Calgary, Canada). Skin integrity was observed at all sites, twice daily, using the National Pressure Ulcer Advisory Panel staging system, for the first seven ICU days and at day 10 and 14.
Results
Of the 132 subjects, 90.9% had no observed changes in skin integrity. Maximum interface pressure was above 32 mmHg virtually 100% of the time for the sacrum, left and right trochanter. At the 45 mmHg level, the left and right trochanter had the greatest amount of time above this level (greater than 95% of the time), followed by the sacrum, left and right scapula, and the left and right heels. Similarly, at levels above 60 mmHg, the same site order applied. For those six subjects with sacral skin integrity changes, maximum pressures were greater than 32 mmHg 100% of the time. Four of the six sacral changes were associated with greater amounts of time above both 45 mmHg and 60 mmHg than the entire sample.
Conclusions
Maximum tissue interface pressure was above critical levels for the majority of the documented periods, especially in the sacrum, although few changes in skin integrity were documented. Time spent above critical levels for mean pressures were considerably less compared to maximum pressures. Maximum pressures may have reflected pressure spikes, but the large amount of time above the critical pressure levels remains substantial.
Grap, MJ et al
Intensive and Critical Care Nursing- Article in Press
To describe tissue interface pressure, time spent above critical pressure levels and the effect on skin integrity at seven anatomical locations.
Objective
To describe tissue interface pressure, time spent above critical pressure levels and the effect on skin integrity at seven anatomical locations.
Design, setting, patients
Descriptive, longitudinal study in critically ill mechanically ventilated adults, from Surgical Trauma ICU-STICU; Medical Respiratory ICU-MRICU; Neuroscience ICU-NSICU in a Mid-Atlantic urban university medical centre. Subjects were enroled in the study within 24 hours of intubation.
Measurements
Tissue interface pressure was measured continuously using the XSENSOR pressure mapping system (XSENSOR Technology Corporation, Calgary, Canada). Skin integrity was observed at all sites, twice daily, using the National Pressure Ulcer Advisory Panel staging system, for the first seven ICU days and at day 10 and 14.
Results
Of the 132 subjects, 90.9% had no observed changes in skin integrity. Maximum interface pressure was above 32 mmHg virtually 100% of the time for the sacrum, left and right trochanter. At the 45 mmHg level, the left and right trochanter had the greatest amount of time above this level (greater than 95% of the time), followed by the sacrum, left and right scapula, and the left and right heels. Similarly, at levels above 60 mmHg, the same site order applied. For those six subjects with sacral skin integrity changes, maximum pressures were greater than 32 mmHg 100% of the time. Four of the six sacral changes were associated with greater amounts of time above both 45 mmHg and 60 mmHg than the entire sample.
Conclusions
Maximum tissue interface pressure was above critical levels for the majority of the documented periods, especially in the sacrum, although few changes in skin integrity were documented. Time spent above critical levels for mean pressures were considerably less compared to maximum pressures. Maximum pressures may have reflected pressure spikes, but the large amount of time above the critical pressure levels remains substantial.
Mild Cognitive Impairment and Risk of Critical Illness
Mild Cognitive Impairment and Risk of Critical Illness
Teeters, D. A et al
Critical Care Medicine: November 2016 - Volume 44 - Issue 11 - p 2045–2051
Objectives: Approximately half of ICU admissions are comprised of patients older than 65 years old. Mild cognitive impairment is a common disorder affecting 10–20% of patients in the same age group. A need exists for exploring mild cognitive impairment and risk of critical illness. As mild cognitive impairment may be a contributor to poorer overall health or be a result of it, we sought to determine whether the presence of mild cognitive impairment independently increases the risk of critical illness admissions.
Design: Data from the Mayo Clinic Study of Aging were analyzed. All study participants underwent prospective comprehensive cognitive testing and expert panel consensus diagnosis of both cognitive function and clinical state at baseline and subsequent visits. Comparisons were made between those with normal cognitive function and mild cognitive impairment regarding baseline health and frequency of critical illness. Setting: Single-center population-based cohort out of Olmsted County, MN. Participants: All individuals 70–89 years old were screened for prospective enrollment in the Mayo Clinic Study of Aging. Patients with preexisting dementia and ICU admission within 3 years of entry to the study were excluded from this analysis. Interventions: None.
Measurements and Main Results: Of 2,425 patients analyzed from the Mayo Clinic Study of Aging, 1,734 patients (71%) were included in the current study. Clinical factors associated with baseline mild cognitive impairment included age, male gender, stroke, and poorer health self-rating. Using a Cox regression model adjusting for these and a priori variables of baseline health, the presence of mild cognitive impairment remained a significant predictor of ICU admission (hazard ratio, 1.50 [1.15–1.96]; p = 0.003).
Conclusions and Relevance: The presence of mild cognitive impairment is independently associated with increased critical illness admission. Further prospective studies are needed to analyze the impact of critical illness on cognitive function.
Teeters, D. A et al
Critical Care Medicine: November 2016 - Volume 44 - Issue 11 - p 2045–2051
Objectives: Approximately half of ICU admissions are comprised of patients older than 65 years old. Mild cognitive impairment is a common disorder affecting 10–20% of patients in the same age group. A need exists for exploring mild cognitive impairment and risk of critical illness. As mild cognitive impairment may be a contributor to poorer overall health or be a result of it, we sought to determine whether the presence of mild cognitive impairment independently increases the risk of critical illness admissions.
Design: Data from the Mayo Clinic Study of Aging were analyzed. All study participants underwent prospective comprehensive cognitive testing and expert panel consensus diagnosis of both cognitive function and clinical state at baseline and subsequent visits. Comparisons were made between those with normal cognitive function and mild cognitive impairment regarding baseline health and frequency of critical illness. Setting: Single-center population-based cohort out of Olmsted County, MN. Participants: All individuals 70–89 years old were screened for prospective enrollment in the Mayo Clinic Study of Aging. Patients with preexisting dementia and ICU admission within 3 years of entry to the study were excluded from this analysis. Interventions: None.
Measurements and Main Results: Of 2,425 patients analyzed from the Mayo Clinic Study of Aging, 1,734 patients (71%) were included in the current study. Clinical factors associated with baseline mild cognitive impairment included age, male gender, stroke, and poorer health self-rating. Using a Cox regression model adjusting for these and a priori variables of baseline health, the presence of mild cognitive impairment remained a significant predictor of ICU admission (hazard ratio, 1.50 [1.15–1.96]; p = 0.003).
Conclusions and Relevance: The presence of mild cognitive impairment is independently associated with increased critical illness admission. Further prospective studies are needed to analyze the impact of critical illness on cognitive function.
Increased Ratio of Visceral to Subcutaneous Adipose Tissue in Septic Patients Is Associated With Adverse Outcome
Increased Ratio of Visceral to Subcutaneous Adipose Tissue in Septic Patients Is Associated With Adverse Outcome
Pisitsak, C et al
Critical Care Medicine: November 2016 - Volume 44 - Issue 11 - p 1966–1973
Objectives: Visceral and subcutaneous adipose tissue may contribute differentially to the septic inflammatory response. Accordingly, we tested the hypothesis that the ratio of visceral to subcutaneous adipose tissue is associated with altered sepsis outcome.
Design: A retrospective analysis from a cohort of sepsis patients admitted between 2004 and 2009. Setting: A mixed medical-surgical ICU at St. Paul’s Hospital in Vancouver, Canada. Patients: Patients older than 16 years old who had sepsis and underwent abdominal CT scan (n = 257) for clinical reasons.
Interventions: None.
Measurements and Main Results: We measured the visceral adipose tissue and subcutaneous adipose tissue areas and calculated the visceral adipose tissue-to-subcutaneous adipose tissue ratio. Visceral adipose tissue/subcutaneous adipose tissue was not correlated with body mass index (r2 = –0.015, p = NS) and therefore provides additional unique information independent of body mass index. Sepsis patients with higher visceral adipose tissue/subcutaneous adipose tissue had greater 90-day mortality than patients with lower visceral adipose tissue/subcutaneous adipose tissue (log-rank test, linear-by linear association p < 0.005). After adjustment for significant covariates using Cox regression, increased visceral adipose tissue/subcutaneous adipose tissue quartile was significantly associated with increased 90-day mortality with hazard ratios of 2.01 (95% CI, 1.01–3.99) for the third visceral adipose tissue/subcutaneous adipose tissue quartile compared with the first quartile and 2.32 (95% CI, 1.15–4.69) for the highest visceral adipose tissue/subcutaneous adipose tissue quartile when compared with the first quartile. Increased mortality for patients with higher visceral adipose tissue/subcutaneous adipose tissue was found for both patients with body mass index less than 25 kg/m2 (p = 0.004) and for body mass index greater than or equal to 25 kg/m2 (p = 0.023). Furthermore, we found significantly greater need for mechanical ventilation, renal replacement therapy, and ICU stay in patients in the highest visceral adipose tissue/subcutaneous adipose tissue quartile. The ratio of proinflammatory (interleukin-8) to anti-inflammatory (interleukin-10) plasma cytokine levels was greater in patients with higher visceral adipose tissue/subcutaneous adipose tissue than in those with lower visceral adipose tissue/subcutaneous adipose tissue (p = 0.043).
Conclusions: Visceral obesity, defined by a high visceral adipose tissue-to-subcutaneous adipose tissue ratio, contributes to adverse outcome in sepsis patients perhaps because of a greater pro- versus anti-inflammatory response.
Pisitsak, C et al
Critical Care Medicine: November 2016 - Volume 44 - Issue 11 - p 1966–1973
Objectives: Visceral and subcutaneous adipose tissue may contribute differentially to the septic inflammatory response. Accordingly, we tested the hypothesis that the ratio of visceral to subcutaneous adipose tissue is associated with altered sepsis outcome.
Design: A retrospective analysis from a cohort of sepsis patients admitted between 2004 and 2009. Setting: A mixed medical-surgical ICU at St. Paul’s Hospital in Vancouver, Canada. Patients: Patients older than 16 years old who had sepsis and underwent abdominal CT scan (n = 257) for clinical reasons.
Interventions: None.
Measurements and Main Results: We measured the visceral adipose tissue and subcutaneous adipose tissue areas and calculated the visceral adipose tissue-to-subcutaneous adipose tissue ratio. Visceral adipose tissue/subcutaneous adipose tissue was not correlated with body mass index (r2 = –0.015, p = NS) and therefore provides additional unique information independent of body mass index. Sepsis patients with higher visceral adipose tissue/subcutaneous adipose tissue had greater 90-day mortality than patients with lower visceral adipose tissue/subcutaneous adipose tissue (log-rank test, linear-by linear association p < 0.005). After adjustment for significant covariates using Cox regression, increased visceral adipose tissue/subcutaneous adipose tissue quartile was significantly associated with increased 90-day mortality with hazard ratios of 2.01 (95% CI, 1.01–3.99) for the third visceral adipose tissue/subcutaneous adipose tissue quartile compared with the first quartile and 2.32 (95% CI, 1.15–4.69) for the highest visceral adipose tissue/subcutaneous adipose tissue quartile when compared with the first quartile. Increased mortality for patients with higher visceral adipose tissue/subcutaneous adipose tissue was found for both patients with body mass index less than 25 kg/m2 (p = 0.004) and for body mass index greater than or equal to 25 kg/m2 (p = 0.023). Furthermore, we found significantly greater need for mechanical ventilation, renal replacement therapy, and ICU stay in patients in the highest visceral adipose tissue/subcutaneous adipose tissue quartile. The ratio of proinflammatory (interleukin-8) to anti-inflammatory (interleukin-10) plasma cytokine levels was greater in patients with higher visceral adipose tissue/subcutaneous adipose tissue than in those with lower visceral adipose tissue/subcutaneous adipose tissue (p = 0.043).
Conclusions: Visceral obesity, defined by a high visceral adipose tissue-to-subcutaneous adipose tissue ratio, contributes to adverse outcome in sepsis patients perhaps because of a greater pro- versus anti-inflammatory response.
Neuromuscular Blocking Agents and Neuromuscular Dysfunction Acquired in Critical Illness: A Systematic Review and Meta-Analysis
Neuromuscular Blocking Agents and Neuromuscular Dysfunction Acquired in Critical Illness: A Systematic Review and Meta-Analysis
Price, D R et al
Critical Care Medicine: November 2016 - Volume 44 - Issue 11 - p 2070–2078
Objective: The relationship between neuromuscular blocking agents and neuromuscular dysfunction acquired in critical illness remains unclear. We examined the association between neuromuscular blocking agents and ICU-acquired weakness, critical illness polyneuropathy, and critical illness myopathy. Data Sources: PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health Literature, and bibliographies of included studies were searched from database inception until September 24, 2015.
Study Selection: Randomized controlled trials and prospective observational studies examining the association between neuromuscular blocking agents and ICU-acquired weakness, critical illness polyneuropathy, or critical illness myopathy. Data Extraction: One author screened titles/abstracts. Two authors independently reviewed full text and extracted data from included studies. Meta-analysis was performed using the DerSimonian-Laird random effects model (OpenMetaAnalyst 10.10 for OS.X). We assessed reporting bias with funnel plots and heterogeneity with the I2 statistic.
Data Synthesis: Of 2,170 titles/abstracts screened, 99 full texts were selected for review, yielding one randomized controlled trial and 18 prospective observational studies, for a total of 2,254 patients. The randomized controlled trial did not show an association between neuromuscular blocking agents and neuromuscular dysfunction acquired in critical illness (odds ratio, 1.21; 95% CI, 0.67–2.19), but pooled data from all included studies suggested a modest association (odds ratio, 1.25; 95% CI, 1.06–1.48; I2 = 16%). Funnel plots suggested reporting bias, and sensitivity analyses showed a disproportionate contribution from critical illness polyneuropathy/critical illness myopathy and severe sepsis/septic shock studies.
Conclusions: This meta-analysis suggests a modest association between neuromuscular blocking agents and neuromuscular dysfunction acquired in critical illness; limitations include studies with a high risk of bias and a disproportionate contribution from studies examining patients for critical illness polyneuropathy/critical illness myopathy and those with severe sepsis/septic shock.
Price, D R et al
Critical Care Medicine: November 2016 - Volume 44 - Issue 11 - p 2070–2078
Objective: The relationship between neuromuscular blocking agents and neuromuscular dysfunction acquired in critical illness remains unclear. We examined the association between neuromuscular blocking agents and ICU-acquired weakness, critical illness polyneuropathy, and critical illness myopathy. Data Sources: PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health Literature, and bibliographies of included studies were searched from database inception until September 24, 2015.
Study Selection: Randomized controlled trials and prospective observational studies examining the association between neuromuscular blocking agents and ICU-acquired weakness, critical illness polyneuropathy, or critical illness myopathy. Data Extraction: One author screened titles/abstracts. Two authors independently reviewed full text and extracted data from included studies. Meta-analysis was performed using the DerSimonian-Laird random effects model (OpenMetaAnalyst 10.10 for OS.X). We assessed reporting bias with funnel plots and heterogeneity with the I2 statistic.
Data Synthesis: Of 2,170 titles/abstracts screened, 99 full texts were selected for review, yielding one randomized controlled trial and 18 prospective observational studies, for a total of 2,254 patients. The randomized controlled trial did not show an association between neuromuscular blocking agents and neuromuscular dysfunction acquired in critical illness (odds ratio, 1.21; 95% CI, 0.67–2.19), but pooled data from all included studies suggested a modest association (odds ratio, 1.25; 95% CI, 1.06–1.48; I2 = 16%). Funnel plots suggested reporting bias, and sensitivity analyses showed a disproportionate contribution from critical illness polyneuropathy/critical illness myopathy and severe sepsis/septic shock studies.
Conclusions: This meta-analysis suggests a modest association between neuromuscular blocking agents and neuromuscular dysfunction acquired in critical illness; limitations include studies with a high risk of bias and a disproportionate contribution from studies examining patients for critical illness polyneuropathy/critical illness myopathy and those with severe sepsis/septic shock.
Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient
Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient
Murray, M J. et al
Critical Care Medicine: November 2016 - Volume 44 - Issue 11 - p 2079–2103
Objective: To update the 2002 version of “Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient.” Design: A Task Force comprising 17 members of the Society of Critical Medicine with particular expertise in the use of neuromuscular-blocking agents; a Grading of Recommendations Assessment, Development, and Evaluation expert; and a medical writer met via teleconference and three face-to-face meetings and communicated via e-mail to examine the evidence and develop these practice guidelines. Annually, all members completed conflict of interest statements; no conflicts were identified. This activity was funded by the Society for Critical Care Medicine, and no industry support was provided.
Methods: Using the Grading of Recommendations Assessment, Development, and Evaluation system, the Grading of Recommendations Assessment, Development, and Evaluation expert on the Task Force created profiles for the evidence related to six of the 21 questions and assigned quality-of-evidence scores to these and the additional 15 questions for which insufficient evidence was available to create a profile. Task Force members reviewed this material and all available evidence and provided recommendations, suggestions, or good practice statements for these 21 questions. Results: The Task Force developed a single strong recommendation: we recommend scheduled eye care that includes lubricating drops or gel and eyelid closure for patients receiving continuous infusions of neuromuscular-blocking agents.
The Task Force developed 10 weak recommendations. 1) We suggest that a neuromuscular-blocking agent be administered by continuous intravenous infusion early in the course of acute respiratory distress syndrome for patients with a PaO2/FIO2 less than 150. 2) We suggest against the routine administration of an neuromuscular-blocking agents to mechanically ventilated patients with status asthmaticus. 3) We suggest a trial of a neuromuscular-blocking agents in life-threatening situations associated with profound hypoxemia, respiratory acidosis, or hemodynamic compromise. 4) We suggest that neuromuscular-blocking agents may be used to manage overt shivering in therapeutic hypothermia. 5) We suggest that peripheral nerve stimulation with train-of-four monitoring may be a useful tool for monitoring the depth of neuromuscular blockade but only if it is incorporated into a more inclusive assessment of the patient that includes clinical assessment. 6) We suggest against the use of peripheral nerve stimulation with train of four alone for monitoring the depth of neuromuscular blockade in patients receiving continuous infusion of neuromuscular-blocking agents. 7) We suggest that patients receiving a continuous infusion of neuromuscular-blocking agent receive a structured physiotherapy regimen. 8) We suggest that clinicians target a blood glucose level of less than 180 mg/dL in patients receiving neuromuscular-blocking agents. 9) We suggest that clinicians not use actual body weight and instead use a consistent weight (ideal body weight or adjusted body weight) when calculating neuromuscular-blocking agents doses for obese patients. 10) We suggest that neuromuscular-blocking agents be discontinued at the end of life or when life support is withdrawn.
In situations in which evidence was lacking or insufficient and the study results were equivocal or optimal clinical practice varies, the Task Force made no recommendations for nine of the topics. 1) We make no recommendation as to whether neuromuscular blockade is beneficial or harmful when used in patients with acute brain injury and raised intracranial pressure. 2) We make no recommendation on the routine use of neuromuscular-blocking agents for patients undergoing therapeutic hypothermia following cardiac arrest. 3) We make no recommendation on the use of peripheral nerve stimulation to monitor degree of block in patients undergoing therapeutic hypothermia. 4) We make no recommendation on the use of neuromuscular blockade to improve the accuracy of intravascular-volume assessment in mechanically ventilated patients. 5) We make no recommendation concerning the use of electroencephalogram-derived parameters as a measure of sedation during continuous administration of neuromuscular-blocking agents. 6) We make no recommendation regarding nutritional requirements specific to patients receiving infusions of neuromuscular-blocking agents. 7) We make no recommendation concerning the use of one measure of consistent weight over another when calculating neuromuscular-blocking agent doses in obese patients. 8) We make no recommendation on the use of neuromuscular-blocking agents in pregnant patients. 9) We make no recommendation on which muscle group should be monitored in patients with myasthenia gravis receiving neuromuscular-blocking agents.
Finally, in situations in which evidence was lacking or insufficient but expert consensus was unanimous, the Task Force developed six good practice statements. 1) If peripheral nerve stimulation is used, optimal clinical practice suggests that it should be done in conjunction with assessment of other clinical findings (e.g., triggering of the ventilator and degree of shivering) to assess the degree of neuromuscular blockade in patients undergoing therapeutic hypothermia. 2) Optimal clinical practice suggests that a protocol should include guidance on neuromuscular-blocking agent administration in patients undergoing therapeutic hypothermia. 3) Optimal clinical practice suggests that analgesic and sedative drugs should be used prior to and during neuromuscular blockade, with the goal of achieving deep sedation. 4) Optimal clinical practice suggests that clinicians at the bedside implement measure to attenuate the risk of unintended extubation in patients receiving neuromuscular-blocking agents. 5) Optimal clinical practice suggests that a reduced dose of an neuromuscular-blocking agent be used for patients with myasthenia gravis and that the dose should be based on peripheral nerve stimulation with train-of-four monitoring. 6) Optimal clinical practice suggests that neuromuscular-blocking agents be discontinued prior to the clinical determination of brain death
Murray, M J. et al
Critical Care Medicine: November 2016 - Volume 44 - Issue 11 - p 2079–2103
Objective: To update the 2002 version of “Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient.” Design: A Task Force comprising 17 members of the Society of Critical Medicine with particular expertise in the use of neuromuscular-blocking agents; a Grading of Recommendations Assessment, Development, and Evaluation expert; and a medical writer met via teleconference and three face-to-face meetings and communicated via e-mail to examine the evidence and develop these practice guidelines. Annually, all members completed conflict of interest statements; no conflicts were identified. This activity was funded by the Society for Critical Care Medicine, and no industry support was provided.
Methods: Using the Grading of Recommendations Assessment, Development, and Evaluation system, the Grading of Recommendations Assessment, Development, and Evaluation expert on the Task Force created profiles for the evidence related to six of the 21 questions and assigned quality-of-evidence scores to these and the additional 15 questions for which insufficient evidence was available to create a profile. Task Force members reviewed this material and all available evidence and provided recommendations, suggestions, or good practice statements for these 21 questions. Results: The Task Force developed a single strong recommendation: we recommend scheduled eye care that includes lubricating drops or gel and eyelid closure for patients receiving continuous infusions of neuromuscular-blocking agents.
The Task Force developed 10 weak recommendations. 1) We suggest that a neuromuscular-blocking agent be administered by continuous intravenous infusion early in the course of acute respiratory distress syndrome for patients with a PaO2/FIO2 less than 150. 2) We suggest against the routine administration of an neuromuscular-blocking agents to mechanically ventilated patients with status asthmaticus. 3) We suggest a trial of a neuromuscular-blocking agents in life-threatening situations associated with profound hypoxemia, respiratory acidosis, or hemodynamic compromise. 4) We suggest that neuromuscular-blocking agents may be used to manage overt shivering in therapeutic hypothermia. 5) We suggest that peripheral nerve stimulation with train-of-four monitoring may be a useful tool for monitoring the depth of neuromuscular blockade but only if it is incorporated into a more inclusive assessment of the patient that includes clinical assessment. 6) We suggest against the use of peripheral nerve stimulation with train of four alone for monitoring the depth of neuromuscular blockade in patients receiving continuous infusion of neuromuscular-blocking agents. 7) We suggest that patients receiving a continuous infusion of neuromuscular-blocking agent receive a structured physiotherapy regimen. 8) We suggest that clinicians target a blood glucose level of less than 180 mg/dL in patients receiving neuromuscular-blocking agents. 9) We suggest that clinicians not use actual body weight and instead use a consistent weight (ideal body weight or adjusted body weight) when calculating neuromuscular-blocking agents doses for obese patients. 10) We suggest that neuromuscular-blocking agents be discontinued at the end of life or when life support is withdrawn.
In situations in which evidence was lacking or insufficient and the study results were equivocal or optimal clinical practice varies, the Task Force made no recommendations for nine of the topics. 1) We make no recommendation as to whether neuromuscular blockade is beneficial or harmful when used in patients with acute brain injury and raised intracranial pressure. 2) We make no recommendation on the routine use of neuromuscular-blocking agents for patients undergoing therapeutic hypothermia following cardiac arrest. 3) We make no recommendation on the use of peripheral nerve stimulation to monitor degree of block in patients undergoing therapeutic hypothermia. 4) We make no recommendation on the use of neuromuscular blockade to improve the accuracy of intravascular-volume assessment in mechanically ventilated patients. 5) We make no recommendation concerning the use of electroencephalogram-derived parameters as a measure of sedation during continuous administration of neuromuscular-blocking agents. 6) We make no recommendation regarding nutritional requirements specific to patients receiving infusions of neuromuscular-blocking agents. 7) We make no recommendation concerning the use of one measure of consistent weight over another when calculating neuromuscular-blocking agent doses in obese patients. 8) We make no recommendation on the use of neuromuscular-blocking agents in pregnant patients. 9) We make no recommendation on which muscle group should be monitored in patients with myasthenia gravis receiving neuromuscular-blocking agents.
Finally, in situations in which evidence was lacking or insufficient but expert consensus was unanimous, the Task Force developed six good practice statements. 1) If peripheral nerve stimulation is used, optimal clinical practice suggests that it should be done in conjunction with assessment of other clinical findings (e.g., triggering of the ventilator and degree of shivering) to assess the degree of neuromuscular blockade in patients undergoing therapeutic hypothermia. 2) Optimal clinical practice suggests that a protocol should include guidance on neuromuscular-blocking agent administration in patients undergoing therapeutic hypothermia. 3) Optimal clinical practice suggests that analgesic and sedative drugs should be used prior to and during neuromuscular blockade, with the goal of achieving deep sedation. 4) Optimal clinical practice suggests that clinicians at the bedside implement measure to attenuate the risk of unintended extubation in patients receiving neuromuscular-blocking agents. 5) Optimal clinical practice suggests that a reduced dose of an neuromuscular-blocking agent be used for patients with myasthenia gravis and that the dose should be based on peripheral nerve stimulation with train-of-four monitoring. 6) Optimal clinical practice suggests that neuromuscular-blocking agents be discontinued prior to the clinical determination of brain death
Patient Recollection of ICU Procedural Pain and Post ICU Burden: The Memory Study
Patient Recollection of ICU Procedural Pain and Post ICU Burden: The Memory Study
Puntillo, K A et al
Critical Care Medicine: November 2016 - Volume 44 - Issue 11 - p 1988–1995
Objective: To assess patients’ recollections of in-ICU procedural pain and its impact on post-ICU burden.
Design: Prospective longitudinal study of patients who underwent ICU procedures. Setting: Thirty-four ICUs in France and Belgium. Patients: Two hundred thirty-six patients who had undergone ICU procedures. Intervention: None.
Measurements and Main Results: Patients were interviewed 3–16 months after hospitalization about: 1) recall of procedural pain intensity and pain distress (on 0–10 numeric rating scale); 2) current pain; that is, having pain in the past week that was not present before hospitalization; and 3) presence of traumatic stress (Impact of Events Scale). For patients who could rate recalled procedural pain intensity (n = 56) and pain distress (n = 43), both were significantly higher than their median (interquartile range) in ICU procedural pain scores (pain intensity: 5 [4–7] vs 3 [2.5–5], p < 0.001; pain distress: 5 [2–6] vs 2 [0–6], p = 0.003, respectively.) Current pain was reported in 14% of patients. When comparing patients with and without current pain, patients with current pain recalled even greater ICU procedural pain intensity and pain distress scores than patients without current pain: pain intensity, 8 (6–8) versus 5 (3.25–7); p = 0.002 and pain distress, 7 (5–8) versus 4 (2–6); p = 0.01, respectively. Patients with current pain also had significantly higher Impact of Events Scale scores than those without current pain (8.5 [3.5–24] vs 2 [0–10]; p < 0.001).
Conclusion: Many patients remembered ICU, with far fewer able to rate procedure-associated pain. For those able to do so, recalled pain intensity and pain distress scores were significantly greater than reported in ICU. One in seven patients was having current pain, recalling even higher ICU procedural pain scores and greater traumatic stress when compared with patients without current pain. Studies are needed to assess the impact of ICU procedural pain on post-ICU pain recall, pain status over time, and the relationship between postdischarge pain status and post-ICU burden.
Puntillo, K A et al
Critical Care Medicine: November 2016 - Volume 44 - Issue 11 - p 1988–1995
Objective: To assess patients’ recollections of in-ICU procedural pain and its impact on post-ICU burden.
Design: Prospective longitudinal study of patients who underwent ICU procedures. Setting: Thirty-four ICUs in France and Belgium. Patients: Two hundred thirty-six patients who had undergone ICU procedures. Intervention: None.
Measurements and Main Results: Patients were interviewed 3–16 months after hospitalization about: 1) recall of procedural pain intensity and pain distress (on 0–10 numeric rating scale); 2) current pain; that is, having pain in the past week that was not present before hospitalization; and 3) presence of traumatic stress (Impact of Events Scale). For patients who could rate recalled procedural pain intensity (n = 56) and pain distress (n = 43), both were significantly higher than their median (interquartile range) in ICU procedural pain scores (pain intensity: 5 [4–7] vs 3 [2.5–5], p < 0.001; pain distress: 5 [2–6] vs 2 [0–6], p = 0.003, respectively.) Current pain was reported in 14% of patients. When comparing patients with and without current pain, patients with current pain recalled even greater ICU procedural pain intensity and pain distress scores than patients without current pain: pain intensity, 8 (6–8) versus 5 (3.25–7); p = 0.002 and pain distress, 7 (5–8) versus 4 (2–6); p = 0.01, respectively. Patients with current pain also had significantly higher Impact of Events Scale scores than those without current pain (8.5 [3.5–24] vs 2 [0–10]; p < 0.001).
Conclusion: Many patients remembered ICU, with far fewer able to rate procedure-associated pain. For those able to do so, recalled pain intensity and pain distress scores were significantly greater than reported in ICU. One in seven patients was having current pain, recalling even higher ICU procedural pain scores and greater traumatic stress when compared with patients without current pain. Studies are needed to assess the impact of ICU procedural pain on post-ICU pain recall, pain status over time, and the relationship between postdischarge pain status and post-ICU burden.
Employment Outcomes After Critical Illness: An Analysis of the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors Cohort
Employment Outcomes After Critical Illness: An Analysis of the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors Cohort
Norman, B C et al
Critical Care Medicine: November 2016 - Volume 44 - Issue 11 - p 2003–2009
Norman, B C et al
Critical Care Medicine: November 2016 - Volume 44 - Issue 11 - p 2003–2009
Objectives: To characterize survivors’ employment status after critical illness and to determine if duration of delirium during hospitalization and residual cognitive function are each independently associated with decreased employment.
Design: Prospective cohort investigation with baseline and in-hospital clinical data and follow-up at 3 and 12 months. Setting: Medical and surgical ICUs at two tertiary-care hospitals. Patients: Previously employed patients from the Bringing to Light the Risk Factors and Incidence of Neuropsychological Dysfunction in ICU Survivors study who survived a critical illness due to respiratory failure or shock were evaluated for global cognition and employment status at 3- and 12-month follow-up.
Measurements and Main Results: We used multivariable logistic regression to evaluate independent associations between employment at both 3 and 12 months and global cognitive function at the same time point, and delirium during the hospital stay. At 3-month follow-up, 113 of the total survival cohort of 448 (25%) were identified as being employed at study enrollment. Of these, 94 survived to 12-month follow-up. At 3- and 12-month follow-up, 62% and 49% had a decrease in employment, 57% and 49% of whom, respectively, were newly unemployed. After adjustment for physical health status, depressive symptoms, marital status, level of education, and severity of illness, we did not find significant predictors of employment status at 3 months, but better cognition at 12 months was marginally associated with lower odds of employment reduction at 12 months (odds ratio, 0.49; p = 0.07).
Conclusions: Reduction in employment after critical illness was present in the majority of our ICU survivors, approximately half of which was new unemployment. Cognitive function at 12 months was a predictor of subsequent employment status. Further research is needed into the potential relationship between the impact of critical illness on cognitive function and employment status.
Quality of Life and Recommendations for Further Care
Quality of Life and Recommendations for Further Care
Putman, M S et al
Critical Care Medicine: November 2016 - Volume 44 - Issue 11 - p 1996–2002
Objectives: Physician recommendations for further medical treatment or palliative treatment only at the end of life may influence patient decisions. Little is known about the patient characteristics that affect physician-assessed quality of life or how such assessments are related to subsequent recommendations.
Design, Setting, and Subjects: A 2010 mailed survey of practicing U.S. physicians (1,156/1,878 or 62% of eligible physicians responded).
Measurements and Main Results: Measures included an end of life vignette with five experimentally varied patient characteristics: setting, alimentation, pain, cognition, and communication. Physicians rated vignette patient quality of life on a scale from 0 to 100 and indicated whether they would recommend continuing full medical treatment or palliative treatment only. Cognitive deficits and alimentation had the greatest impacts on recommendations for further care, but pain and communication were also significant (all p < 0.001). Physicians who recommended continuing full medical treatment rated quality of life three times higher than those recommending palliative treatment only (40.41 vs 12.19; p < 0.01). Religious physicians were more likely to assess quality of life higher and to recommend full medical treatment.
Conclusions: Physician judgments about quality of life are highly correlated with recommendations for further care. Patients and family members might consider these biases when negotiating medical decisions.
Developing professional habits of hand hygiene in intensive care settings: An action-research intervention
Developing professional habits of hand hygiene in intensive care settings: An action-research intervention
Battistella G, Bazzo S.
Critical Care Nursing - Article in Press
To explore perceptions and unconscious psychological processes underlying handwashing behaviours of intensive care nurses, to implement organisational innovations for improving hand hygiene in clinical practice.
Battistella G, Bazzo S.
Critical Care Nursing - Article in Press
To explore perceptions and unconscious psychological processes underlying handwashing behaviours of intensive care nurses, to implement organisational innovations for improving hand hygiene in clinical practice.
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