Delivering Cognitive Behavioral Therapy for Post-Intensive Care Syndrome-Family via a Mobile Health App.
Petrinec Amy,Wilk Cindy,Hughes Joel W,Zullo Melissa D,Chen Yea-Jyh,Palmieri Patrick A
American journal of critical care : an official publication, American Association of Critical-Care Nurses
BACKGROUND:Family members of intensive care unit (ICU) patients are at risk for post-intensive care syndrome- family (PICS-F), including symptoms of anxiety, depression, and posttraumatic stress. Cognitive behavioral therapy is the first-line nonpharmacologic treatment for many psychological symptoms and has been successfully delivered by use of mobile technology for symptom self-management. OBJECTIVES:To determine the feasibility of delivering cognitive behavioral therapy through a smartphone app to family members of critically ill patients. METHODS:This was a prospective longitudinal cohort study with a consecutive sample of patients admitted to 2 adult ICUs and their family members. The control group period was followed by the intervention group period. The intervention consisted of a mobile health app preloaded on a smartphone provided to family members. The study time points were enrollment (within 5 days of ICU admission), 30 days after admission, and 60 days after admission. Study measures included demographic data, app use, satisfaction with the app, mental health self-efficacy, and measures of PICS-F symptoms. RESULTS:The study sample consisted of 49 predominantly White (92%) and female (82%) family members (24 intervention, 25 control). Smartphone ownership was 88%. Completion rates for study measures were 92% in the control group and 79% in the intervention group. Family members logged in to the app a mean of 18.58 times (range 2-89) and spent a mean of 81.29 minutes (range 4.93-426.63 minutes) using the app. CONCLUSIONS:The study results confirm the feasibility of implementing app-based delivery of cognitive behavioral therapy to family members of ICU patients.
Post-intensive Care Syndrome: an Overview.
Rawal Gautam,Yadav Sankalp,Kumar Raj
Journal of translational internal medicine
Survival of critically unwell patients has improved in the last decade due to advances in critical care medicine. Some of these survivors develop cognitive, psychiatric and /or physical disability after treatment in intensive care unit (ICU), which is now recognized as post intensive care syndrome (PICS). Given the limited awareness about PICS in the medical faculty this aspect is often overlooked which may lead to reduced quality of life and cause a lot of suffering of these patients and their families. Efforts should be directed towards preventing PICS by minimizing sedation and early mobilization during ICU.All critical care survivors should be evaluated for PICS and those having signs and symptoms of it should be managed by a multidisciplinary team which includes critical care physician, neuro-psychiatrist, physiotherapist and respiratory therapist, with the use of pharmacological and non-apharmacological interventions. This can be achieved through an organizational change and improvement, knowing the high rate of incidence of PICS and its adverse effects on the survivor's life and daily activities and its effect on the survivor's family.
Patients suffering from psychological impairments following critical illness are in need of information.
Journal of intensive care
BACKGROUND:Because critical illness survivors frequently experience several long-term psychological impairments altering quality of life after ICU, there is a trend towards increasing follow-up care, mainly via ICU follow-up clinics. Despite these and other initiatives, understanding of patient's post-ICU needs to help them cope with their problems and subsequently improve quality of life is largely lacking. Our aim was therefore to assess the needs, expectations and wishes in ICU survivors to receive information with the purpose to help them better grasp ICU treatment. In addition, we assessed the perceived burden of psychological trauma after ICU treatment and the health-related quality of life (HRQoL) up to 2.5 years after ICU discharge. METHODS:In a multicentre, retrospective cross-sectional cohort study, the needs and preferred intervention methods were assessed using a self-composed inventory in adult mechanically ventilated ICU survivors ( = 43). Additionally, the Impact of Event Scale Revised, the Beck Depression Inventory, the EuroQol-5D-5L, and the Short-Form 12 were used to assess psychological burden and HRQoL. RESULTS:A substantial proportion of all ICU survivors (59%, 95% CI 44% to 74%) suffered from psychological impairments after ICU treatment. Seventy-five percent of these patients expressed a wish to receive information, but only 36% desired to receive this information using a commonly used information brochure. In contrast, 71% of these patients had a wish to receive information using a video film/VR. Furthermore, only 33% of these patients was satisfied with the information provided by their treating hospital. Patients with psychological PICS reported a worse HRQoL as compared to a normative Dutch sample ( < 0.001) and as compared to patients without psychological PICS ( < 0.01). CONCLUSIONS:In a Dutch cohort of critical illness survivors, a substantial part of ICU survivors suffer from psychological impairments, such as PTSD and depression, which was associated with a worse HRQoL. These patients are in need of information, have no desire using an information brochure, but are willing to receive information using a video film/virtual reality module. These results support the exploration of such an intervention.
Beginning Restorative Activities Very Early: Implementation of an Early Mobility Initiative in a Pediatric Onco-Critical Care Unit.
Ghafoor Saad,Fan Kimberly,Williams Sarah,Brown Amanda,Bowman Sarah,Pettit Kenneth L,Gorantla Shilpa,Quillivan Rebecca,Schwartzberg Sarah,Curry Amanda,Parkhurst Lucy,James Marshay,Smith Jennifer,Canavera Kristin,Elliott Andrew,Frett Michael,Trone Deni,Butrum-Sullivan Jacqueline,Barger Cynthia,Lorino Mary,Mazur Jennifer,Dodson Mandi,Melancon Morgan,Hall Leigh Anne,Rains Jason,Avent Yvonne,Burlison Jonathan,Wang Fang,Pan Haitao,Lenk Mary Anne,Morrison R Ray,Kudchadkar Sapna R
Frontiers in oncology
Introduction:Children with underlying oncologic and hematologic diseases who require critical care services have unique risk factors for developing functional impairments from pediatric post-intensive care syndrome (PICS-p). Early mobilization and rehabilitation programs offer a promising approach for mitigating the effects of PICS-p in oncology patients but have not yet been studied in this high-risk population. Methods:We describe the development and feasibility of implementing an early mobility quality improvement initiative in a dedicated pediatric onco-critical care unit. Our primary outcomes include the percentage of patients with consults for rehabilitation services within 72 h of admission, the percentage of patients who are mobilized within 72 h of admission, and the percentage of patients with a positive delirium screen after 48 h of admission. Results:Between January 2019 and June 2020, we significantly increased the proportion of patients with consults ordered for rehabilitation services within 72 h of admission from 25 to 56% (<0.001), increased the percentage of patients who were mobilized within 72 h of admission to the intensive care unit from 21 to 30% (=0.02), and observed a decrease in patients with positive delirium screens from 43 to 37% (=0.46). The early mobility initiative was not associated with an increase in unplanned extubations, unintentional removal of central venous catheters, or injury to patient or staff. Conclusions:Our experience supports the safety and feasibility of early mobility initiatives in pediatric onco-critical care. Additional evaluation is needed to determine the effects of early mobilization on patient outcomes.
The impact of the patient post-intensive care syndrome components upon caregiver burden.
Torres J,Carvalho D,Molinos E,Vales C,Ferreira A,Dias C C,Araújo R,Gomes E
OBJECTIVE:To evaluate patient post-intensive care syndrome (PICS-P) and caregiver burden 3 months after discharge from the Intensive Care Unit (ICU) and determine the impact of different components of PICS-P upon caregiver burden. DESIGN:A prospective observational study was conducted over 26 months (January 2013-February 2015). SETTING:Medical-surgical ICU and follow-up consultation in Portugal. PATIENTS OR PARTICIPANTS:Patients discharged after a minimum of 2 days in the ICU. Caregiver inclusion criteria: not paid, written and spoken Portuguese, and agreement to participate in the study. MAIN VARIABLES OF INTEREST:In ICU: Patient gender, age, severity of illness (SAPS II) and length of ICU stay. At 3 months caregiver burden, physical (reduced mobility, weakness acquired in the ICU) and psychological components of PICS (anxiety, depression, post-traumatic stress disorder). RESULTS:A total of 168 caregivers completed the survey (response rate of 69%). A low degree of overburden was reported by 34.5% of caregivers, while 15.5% showed moderate to high levels of overburden. Patient anxiety and depression 3 months after ICU discharge significantly influenced the presence of caregiver burden (p=0.030 vs p=0.008). When physical components of PICS-P were evaluated, no influence on caregiver burden was observed. Patient demographics, severity of illness and length of stay also failed to influence caregiver burden. CONCLUSIONS:The presence of psychological components of PICS-P 3 months after ICU seems to have a negative impact upon caregiver burden. On the other hand, physical problems showed no important impact upon caregiver overburden.
Association between intensive care unit admission of a patient and mental disorders in the spouse: a retrospective matched-pair cohort study.
Miyamoto Yuki,Ohbe Hiroyuki,Goto Tadahiro,Yasunaga Hideo
Journal of intensive care
BACKGROUND:Previous prospective studies have suggested that spouses of patients who are admitted to the intensive care unit (ICU) have a high prevalence of mental disorders, termed post-intensive care syndrome-family (PICS-F). However, it remains unclear whether the patient's ICU admission is associated with the occurrence of mental disorders in the spouse outside of the prospective study setting. We therefore investigated the proportion of ICU patients' spouses who visited medical facilities for mental disorders and the association between ICU admission of a patient and mental disorders in the spouse using real-world data. METHODS:This was a retrospective matched-pair cohort study using commercially available, routinely collected administrative claims data. As the study population, we identified all married couples (both wife and husband) who were registered in the database from 1 April 2012 to 31 August 2018 using family identification codes. We identified spouses of patients who were admitted to the ICU for more than 2 days as the exposure group and defined the date of admission to the ICU as the index date. We randomly matched four individuals in the non-exposure group with one individual in the exposure group. The primary outcome was any PICS-F-related mental disorder in the spouses within 6 months from the index date. As a sensitivity analysis, we also investigated the proportion and association of individuals (excluding spouses) with a history of mental disorders. RESULTS:Among 1,082,208 married couples, we identified 8490 spouses of ICU patients, and they were matched with 33,946 individuals. The proportion of any PICS-F-related mental disorder within 6 months from the index date was 12.8% in ICU patients' spouses and 11.3% in the matched individuals (adjusted odds ratio, 1.29; 95% confidence interval, 1.03-1.42). The sensitivity analysis showed significant associations between ICU admission and spouses' mental disorders. CONCLUSIONS:Spouses of patients who were admitted to the ICU had a slightly higher risk of mental disorders within 6 months than spouses of patients who were not admitted to the ICU.
Aging and Postintensive Care Syndrome- Family: A Critical Need for Geriatric Psychiatry.
Serrano Patricia,Kheir You Na P,Wang Sophia,Khan Sikandar,Scheunemann Leslie,Khan Babar
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry
Postintensive care syndrome-family (PICS-F) describes the psychological symptoms that affect the family members of patients hospitalized in the intensive care unit (ICU) or recently discharged from the ICU. Geriatric psychiatrists should be concerned about PICS-F for several reasons. First, ICU hospitalization in older adults is associated with higher rates of cognitive and physical impairment compared with older adults hospitalized in non-ICU settings or dwelling in the community. This confers a special burden on the caregivers of these older ICU survivors compared with other geriatric populations. Second, as caregivers themselves age, caring for this unique burden can be more challenging compared with other geriatric populations. Third, evidence for models of care centered on patients with multimorbidity and their caregivers is limited. A deeper understanding of how to care for PICS and PICS-F may inform clinical practice for other geriatric populations with multimorbidity and their caregivers. Geriatric psychiatrists may play a key role in delivering coordinated care for PICS-F by facilitating timely diagnosis and interdisciplinary collaboration, advocating for the healthcare needs of family members suffering from PICS-F, and leading efforts within healthcare systems to increase awareness and treatment of PICS-F. This clinical review will appraise the current literature about the impact of critical illness on the family members of ICU survivors and identify crucial gaps in our knowledge about PICS-F among aging patients and caregivers.
Improving the Patient Experience by Implementing an ICU Diary for Those at Risk of Post-intensive Care Syndrome.
Blair K Taylor A,Eccleston Sarah D,Binder Hannah M,McCarthy Mary S
Journal of patient experience
The critical care literature in the US has recently brought attention to the impact an ICU experience can have long after the patient survives critical illness, particularly if delirium was present. Current recommendations to mitigate post-intensive care syndrome (PICS) are embedded in patient and family-centered care and aim to promote family presence in the ICU, provide support for decision-making, and enhance communication with the health-care team. Evidence-based interventions are few in number but include use of an ICU diary to minimize the psychological and emotional sequelae affecting patients and family members in the months following the ICU stay. In this paper we describe our efforts to implement an ICU diary and solicit feedback on its role in fostering teamwork and communication between patients, family members, and ICU staff. Next steps will involve a PICS follow-up clinic where trained staff will coordinate specialty referrals and perform long-term monitoring of mental health and other quality of life outcomes.
Transitions from short to long-term outcomes in pediatric critical care: considerations for clinical practice.
Most children are surviving critical illness in highly resourced pediatric intensive care units (PICUs). However, in research studies, many of these children survive with multi-domain health sequelae that has the potential to affect development over many years, termed post-intensive care syndrome-pediatrics (PICS-p). Clinically, there are no recommendations for the assessment and follow-up of children with critical illness as exists for the premature neonatal and congenital heart disease populations. In research studies, primary and secondary outcomes are largely assessed at or prior to hospital discharge, disregarding post-hospital outcomes important to PICU stakeholders. Incorporating longer term outcomes into clinical and research programs, however, can no longer be overlooked. Barriers to outcomes assessments are varied and generalized individualized, but some PICU centers are discovering how to overcome them and are providing this service to families-sometimes specific populations-in need. Research programs and funders are increasingly recognizing the value and need to assess long-term outcomes post-PICU. Finally, we should seek the strong backing of the PICU community and families to insist that long-term outcomes become our new clinical standard of care. PICUs should consider development of a multicenter, multinational collaborative to assess clinical outcomes and optimize care delivery and patient and family outcomes. The aim of this review is to present the potential considerations of implementing long-term clinical follow-up following pediatric critical illness.
Piloting an ICU follow-up clinic to improve health-related quality of life in ICU survivors after a prolonged intensive care stay (PINA): study protocol for a pilot randomised controlled trial.
Rohr M,Brandstetter S,Bernardi C,Fisser C,Drewitz K P,Brunnthaler V,Schmidt K,Malfertheiner M V,Apfelbacher C J
Pilot and feasibility studies
BACKGROUND:Intensive care unit (ICU) survivors often suffer from cognitive, physical and mental impairments, known as post-intensive care syndrome (PICS). ICU follow-up clinics may improve aftercare of these patients. There is a lack of evidence whether or which concept of an ICU follow-up clinic is effective. Within the PINA study, a concept for an ICU follow-up clinic was developed and will be tested in a pilot randomised controlled trial (RCT), primarily to evaluate the feasibility and additionally the potential efficacy. METHODS/DESIGN:Design: Pilot RCT with intervention and control (usual care) arms plus mixed-methods process evaluation. PARTICIPANTS:100 ICU patients (50 per arm) of three ICUs in a university hospital (Regensburg, Germany), ≥ 18 years with an ICU stay of > 5 days, a sequential organ failure assessment (SOFA) score > 5 during the ICU stay and a life expectancy of more than 6 months. INTERVENTION:The intervention will contain three components: information, consultation and networking. Information will be available in form of an intensive care guide for patients and next of kin at the ICU and phone support during follow-up. For consultation, patients will visit the ICU follow-up clinic at least once during the first 6 months after discharge from ICU. During these visits, patients will be screened for symptoms of PICS and, if required, referred to specialists for further treatment. The networking part (e.g. special referral letter from the ICU follow-up clinic) aims to provide a network of outpatient care providers for former ICU patients. Feasibility Outcomes: Qualitative and quantitative evaluation will be used to explore reasons for non-participation and the intervention´s acceptability to patients and caregivers. Efficacy Outcomes: Health-related quality of life (HRQOL) will be assessed as primary outcome by the physical component score (PCS) of the Short-Form 12 Questionnaire (SF-12). Secondary outcomes encompass further patient-reported outcomes. All outcomes are assessed at 6 months after discharge from ICU. DISCUSSION:The PINA study will determine feasibility and potential efficacy of a complex intervention in a pilot RCT to enhance follow-up care of ICU survivors. The pilot study is an important step for further studies in the field of ICU aftercare and especially for the implementation of a pragmatic multi-centre RCT. TRIAL REGISTRATION:ClinicalTrials.gov , NCT04186468 . Submitted 2 December 2019.
The intensive care medicine clinical research agenda in paediatrics.
Peters Mark J,Argent Andrew,Festa Marino,Leteurtre Stéphane,Piva Jefferson,Thompson Ann,Willson Douglas,Tissières Pierre,Tucci Marisa,Lacroix Jacques
Intensive care medicine
BACKGROUND:Intensive Care Medicine set us the task of outlining a global clinical research agenda for paediatric intensive care (PIC). In line with the clinical focus of this journal, we have limited this to research that may directly influence patient care. METHODS:Clinician researchers from PIC research networks of varying degrees of formality from around the world were invited to answer two main questions: (1) What have been the major recent advances in paediatric critical care research? (2) What are the top 10 studies for the next 10 years? RESULTS:(1) Inclusive databases are well established in many countries. These registries allow detailed observational studies and feasibility testing of clinical trial protocols. Recent trials are larger and more valuable, and (2) most common interventions in PIC are not evidenced-based. Clinical studies for the next 10 years should address this deficit, including: ventilation techniques and interfaces; fluid, transfusion and feeding strategies; optimal targets for vital signs; multiple organ failure definitions, mechanisms and treatments; trauma, prevention and treatment; improving safety; comfort of the patient and their family; appropriate care in the face of medical complexity; defining post-PICU outcomes; and improving knowledge generation and adoption, with novel trial design and implementation strategies. The group specifically highlighted the need for research in resource-limited environments wherein mortality remains often tenfold higher than in well-resourced settings. CONCLUSION:Paediatric intensive care research has never been healthier, but many gaps in knowledge remain. We need to close these urgently. The impact of new knowledge will be greatest in resource-limited environments.
Neuropsychiatric assessment and management of the ICU survivor.
Dean Erin A,Biehl Michelle,Bash Kathryn,Weleff Jeremy,Pozuelo Leopoldo
Cleveland Clinic journal of medicine
Any survivor among the millions of patients admitted to the intensive care unit (ICU) for critical illness each year is susceptible to persistent health problems that continue after discharge and may lead to post-intensive care syndrome (PICS), defined as new or worsening dysfunction from physical impairment, cognitive impairment, or emotional impairment, or a combination. Considering the increased rates of ICU survival and the growing elderly population more likely to utilize ICU resources, critical care practitioners have broadened their focus on outcomes and care of ICU survivors to include the acute post-ICU survival period as well as months and even years after ICU discharge. This review focuses on the neuropsychiatric aspects of PICS in ICU survivors including diagnostic, screening, and treatment recommendations. It also highlights the value of post-ICU clinics and the unique role of the consultation psychiatrist in the care of this patient population.
Combination of delirium and coma predicts psychiatric symptoms at twelve months in critically ill patients: A longitudinal cohort study.
Miyamoto Kyohei,Shibata Mami,Shima Nozomu,Nakashima Tsuyoshi,Kida Maki,Matsumoto Haruka,Oka Natsuki,Yazaki Akina,Uchigaki Akiko,Takemoto Aya,Kato Seiya,
Journal of critical care
PURPOSE:We aimed to determine any associations between delirium and comas during intensive care unit (ICU) stay, and long-term psychiatric symptoms and disability affecting activity of daily living (ADL). MATERIALS AND METHODS:In this prospective observational study, we enrolled critically ill adult patients that were emergently admitted to an ICU. We assessed psychiatric symptoms and disability affecting ADL at three and twelve months after ICU discharge. RESULTS:Among the 81 and the 47 patients that responded to the questionnaires at three and twelve months, 22 (27%) and 13 (28%) patients experienced delirium, respectively. During their ICU stay, 28 (35%) and 21 (45%) had been in comas, respectively. At three and twelve months, 51 (63%) and 23 (49%) of patients experienced composite psychiatric symptoms or disability affecting ADL, respectively. After adjusting predefined confounders, the combination of delirium and comas was an independent risk factor for the presence of composite psychiatric symptoms or disability affecting ADL (adjusted odds ratio [aOR] 3.38; 1.10-10.38 at three months; aOR 8.28; 1.48-46.46 at twelve months). CONCLUSIONS:In critically ill adults, combination of delirium and comas during ICU stay is a predictor of psychiatric symptoms or ADL disability. TRIAL REGISTRATION:UMIN Clinical Trial Registry no. UMIN000023743, September 1, 2016.
Post-Intensive-Care Syndrome for the Pediatric Neurologist.
Hartman Mary E,Williams Cydni N,Hall Trevor A,Bosworth Christopher C,Piantino Juan A
The number of children who survive critical illness has steadily increased. However, lower mortality rates have resulted in a proportional increase in post-intensive-care morbidity. Critical illness in childhood affects a child's development, cognition, and family functioning. The constellation of physical, emotional, cognitive, and psychosocial symptoms that begin in the intensive care unit and continue after discharge has recently been termed post-intensive-care syndrome. A conceptual model of the post-intensive-care syndrome experienced by children who survive critical illness, their siblings, and parents has been coined post-intensive-care syndrome in pediatrics. Owing to their prolonged hospitalizations, the use of sedative medications, and the nature of their illness, children with primary neurological injury are among those at the highest risk for post-intensive-care syndrome in pediatrics. The pediatric neurologist participates in the care of children with acute brain injury throughout their hospitalization and remains involved after the patient leaves the hospital. Hence it is important for pediatric neurologists to become versed in the early recognition and management of post-intensive-care syndrome in pediatrics. In this review, we discuss the current knowledge regarding post-intensive-care syndrome in pediatrics and its risk factors. We also discuss our experience establishing Pediatric Neurocritical Care Recovery Programs at two large academic centers. Last, we provide a battery of validated tests to identify and manage the different aspects of post-intensive-care syndrome in pediatrics, which have been successfully implemented at our institutions. Dissemination of this "road map" may assist others interested in establishing recovery programs, therefore mitigating the burden of post-intensive-care morbidity in children.
Long-term complications of COVID-19 in ICU survivors: what do we know?
Rasulo Frank A,Piva Simone,Latronico Nicola
Coronavirus disease 2019 (COVID-19) has caused more than 175 million persons infected and 3.8 million deaths so far and is having a devastating impact on both low and high-income countries, in particular on hospitals and Intensive Care Units (ICU). The ICU mortality during the first pandemic wave ranged from 40% to 85% during the busiest ICU period for admissions around the peak of the surge, and those surviving are frequently faced with impairments affecting physical, cognitive, and mental health status, complicating the postacute phase of COVID-19, which in the pre-COVID period, were defined collectively as postintensive care syndrome (PICS). Long COVID is defined as four weeks of persisting symptoms after the acute illness, and post-COVID syndrome and chronic COVID-19 are the proposed terms to describe continued symptomatology for more than 12 weeks. Overall, 50% of ICU survivors suffer from new physical, mental, and/or cognitive problems at 1 year after ICU discharge. The prevalence, severity, and duration of the various impairments in ICU survivors are poorly defined, with substantial variations among published series, and may reflect differences in the timing of assessment, the outcome measured, the instruments utilized, and thresholds adopted to establish the diagnosis, the qualification of personnel delivering the tests, the resource availability as well diversity in patients' case-mix. Future longitudinal studies of adequate sample size with repeated assessments of validated outcomes and comparison with non-COVID-19 ICU patients are needed to fully explore the long-term outcome of ICU patients with COVID-19. In this article, we focus on chronic COVID-19 in ICU survivors and present state-of-the-art data regarding long-term complications related to critical illness and the treatments and organ support received.
Chronic Critical Illness and PICS Nutritional Strategies.
Rosenthal Martin D,Vanzant Erin L,Moore Frederick A
Journal of clinical medicine
The nutritional hallmark of chronic critical illness (CCI) after sepsis is persistent inflammation, immunosuppression, and catabolism syndrome (PICS), which results in global resistance to the anabolic effect of nutritional supplements. This ultimately leaves these patients in a downward phenotypic spiral characterized by cachexia with profound weakness, decreased capacity for rehabilitation, and immunosuppression with the propensity for sepsis recidivism. The persistent catabolism is driven by a pathologic low-grade inflammation with the inability to return to homeostasis and by ongoing increased energy expenditure. Better critical care support systems and advances in technology have led to increased intensive care unit (ICU) survival, but CCI due to PICS with poor long-term outcomes has emerged as a frequent phenotype among ICU sepsis survivors. Unfortunately, therapies to mitigate or reverse PICS-CCI are limited, and recent evidence supports that these patients fail to respond to early ICU evidence-based nutrition protocols. A lack of randomized controlled trials has limited strong recommendations for nutrition adjuncts in these patients. However, based on experience in other conditions characterized by a similar phenotype, immunonutrients aimed at counteracting inflammation, immunosuppression, and catabolism may be important for improving outcomes in PICS-CCI patients. This manuscript intends to review several immunonutrients as adjunctive therapies in treating PICS-CCI.
Caregiver strain and posttraumatic stress symptoms of informal caregivers of intensive care unit survivors.
van den Born-van Zanten Sascha A,Dongelmans Dave A,Dettling-Ihnenfeldt Daniela,Vink Roel,van der Schaaf Marike
BACKGROUND:Many intensive care unit survivors (ICU) are confronted with undesirable and long-lasting impairments in physical, cognitive, and mental health, but not only patients are at risk of developing this post-intensive care syndrome (PICS). Family members can experience symptoms of depression, anxiety, and posttraumatic stress disorder (PTSD). This cluster of complications is called PICS-family. OBJECTIVE:To describe the level of caregiver strain and posttraumatic stress-related symptoms in relatives of ICU survivors. METHODS:We conducted a cohort study in a general hospital between July 2010 and May 2014. Relatives of ICU survivors, mechanically ventilated for > 48 h in the ICU, were asked to complete a questionnaire 3 months after discharge from critical care. Symptoms of PTSD and caregiving concerns were assessed using the Trauma Screening Questionnaire and the Caregiver Strain Index (CSI). RESULTS:A total of 94 relatives visiting our post-ICU clinic completed the questionnaires. Twenty-one percent of the caregivers had a CSI score of 7 or more, indicating high levels of strain. Six percent had CSI scores indicating severe strain (CSI > 10). PTSD-related symptoms were seen in 21% of the caregivers. The mean time spent on caregiving was 10 h (interquartile range 6-17 h) per week. CONCLUSION:This study shows that relatives of ICU survivors could experience strain 3 months after hospital discharge and are at risk of developing PTSD-related symptoms. This complements existing data that relatives are at risk of psychological symptoms. Knowledge can lead to improvements and means to prevent these symptoms. (PsycINFO Database Record
Patients' experiences of recovery: Beyond the intensive care unit and into the community.
Calkins Kelly,Kako Peninnah,Guttormson Jill
Journal of advanced nursing
AIMS:To understand barriers and facilitators of recovery for critical illness survivors', who are discharged home from the hospital and do not have access to dedicated outpatient care. DESIGN:Multi-site descriptive study guided by interpretive phenomenology using semi-structured interviews. METHODS:Interviews were conducted between December 2017 -July 2018. Eighteen participants were included. Data were collected from interview recordings, transcripts, field notes, and a retrospective chart review for sample demographics. Analysis was completed using Interpretive Phenomenological Analysis which provided a unique view of recovery through the survivors' personal experiences and perception of those experiences. RESULTS:Participants encountered several barriers to their recovery; however, they were resilient and initiated ways to overcome these barriers and assist with their recovery. Facilitators of recovery experienced by survivors included seeking support from family and friends, lifestyle adaptations, and creative management of their multiple medical needs. Barriers included unmet needs experienced by survivors such as mental health issues, coordination of care, and spiritual needs. These unmet needs left participants feeling unsupported from healthcare providers during their recovery. CONCLUSION:This study highlights important barriers and facilitators experienced by critical illness survivors during recovery that need be addressed by healthcare providers. New ways to support critical illness survivors, that can reach a broader population, must be developed and evaluated to support survivors during their recovery in the community. IMPACT:This study addressed ICU survivors' barriers and facilitators to recovery. Participants encountered several barriers to recovery at home, such as physical, cognitive, psychosocial, financial, and transportation barriers, however, these survivors were also resilient and resourceful in the development of strategies to try to manage their recovery at home. These results will help healthcare providers develop interventions to better support ICU survivors in the community.
[Recommendation of respiratory rehabilitation for PICS in critically ill patients with COVID-19].
Zhonghua jie he he hu xi za zhi = Zhonghua jiehe he huxi zazhi = Chinese journal of tuberculosis and respiratory diseases
The critically illsurvivors with COVID-19 have Post-Intensive Care Syndrome (PICS) manifestations of varying degrees of physical, cognitive, and mental disorders after discharge from the Intensive Care Unit. Comprehensive respiratory rehabilitation interventions for patients are essential to minimize disability rate, reduce medical costs, and increase social participation. Integrated the existing treatment experience and relevant literature evidence, we recommend the evaluation and intervention of respiratory rehabilitation in the two stages of discharge ICUto ward and home. Based on Chinese experience, a PCCM physician-led multidisciplinary team management process was constructed. Personal protection recommendations were made based on the potential risk of infection among critically ill COVID-19 survivors.
Muscle mass and physical recovery in ICU: innovations for targeting of nutrition and exercise.
Wischmeyer Paul E,Puthucheary Zudin,San Millán Iñigo,Butz Daniel,Grocott Michael P W
Current opinion in critical care
PURPOSE OF REVIEW:We have significantly improved hospital mortality from sepsis and critical illness in last 10 years; however, over this same period we have tripled the number of 'ICU survivors' going to rehabilitation. Furthermore, as up to half the deaths in the first year following ICU admission occur post-ICU discharge, it is unclear how many of these patients ever returned home or a meaningful quality of life. For those who do survive, recent data reveals many 'ICU survivors' will suffer significant functional impairment or post-ICU syndrome (PICS). Thus, new innovative metabolic and exercise interventions to address PICS are urgently needed. These should focus on optimal nutrition and lean body mass (LBM) assessment, targeted nutrition delivery, anabolic/anticatabolic strategies, and utilization of personalized exercise intervention techniques, such as utilized by elite athletes to optimize preparation and recovery from critical care. RECENT FINDINGS:New data for novel LBM analysis technique such as computerized tomography scan and ultrasound analysis of LBM are available showing objective measures of LBM now becoming more practical for predicting metabolic reserve and effectiveness of nutrition/exercise interventions. 13C-Breath testing is a novel technique under study to predict infection earlier and predict over-feeding and under-feeding to target nutrition delivery. New technologies utilized routinely by athletes such as muscle glycogen ultrasound also show promise. Finally, the role of personalized cardiopulmonary exercise testing to target preoperative exercise optimization and post-ICU recovery are becoming reality. SUMMARY:New innovative techniques are demonstrating promise to target recovery from PICS utilizing a combination of objective LBM and metabolic assessment, targeted nutrition interventions, personalized exercise interventions for prehabilitation and post-ICU recovery. These interventions should provide hope that we will soon begin to create more 'survivors' and fewer victim's post-ICU care.
Socioeconomic Factors and Intensive Care Unit-Related Cognitive Impairment.
Haddad Diane N,Mart Matthew F,Wang Li,Lindsell Christopher J,Raman Rameela,Nordness Mina F,Sharp Kenneth W,Pandharipande Pratik P,Girard Timothy D,Ely E Wesley,Patel Mayur B
Annals of surgery
OBJECTIVE:We aimed to identify socioeconomic and clinical risk factors for post-intensive care unit (ICU)-related long-term cognitive impairment (LTCI). SUMMARY BACKGROUND DATA:After delirium during ICU stay, LTCI has been increasingly recognized, but without attention to socioeconomic factors. METHODS:We enrolled a prospective, multicenter cohort of ICU survivors with shock or respiratory failure from surgical and medical ICUs across 5 civilian and Veteran Affairs (VA) hospitals from 2010 to 2016. Our primary outcome was LTCI at 3- and 12 months post-hospital discharge defined by the Repeatable Battery for Assessment of Neuropsychological Symptoms (RBANS) global score. Covariates adjusted using multivariable linear regression included age, sex, race, AHRQ socioeconomic index, Charlson comorbidity, Framingham stroke risk, Sequential Organ Failure Assessment, duration of coma, delirium, hypoxemia, sepsis, education level, hospital type, insurance status, discharge disposition, and ICU drug exposures. RESULTS:Of 1040 patients, 71% experienced delirium, and 47% and 41% of survivors had RBANS scores >1 standard deviation below normal at 3- and 12 months, respectively. Adjusted analysis indicated that delirium, non-White race, lower education, and civilian hospitals (as opposed to VA), were associated with at least a half standard deviation lower RBANS scores at 3- and 12 months (P ≤ 0.03). Sex, AHRQ socioeconomic index, insurance status, and discharge disposition were not associated with RBANS scores. CONCLUSIONS:Socioeconomic and clinical risk factors, such as race, education, hospital type, and delirium duration, were linked to worse PICS ICU-related, LTCI. Further efforts may focus on improved identification of higher-risk groups to promote survivorship through emerging improvements in cognitive rehabilitation.
Evaluating the Feasibility and Efficacy of a Pediatric Intensive Care Unit Diary.
Wang Shu-Heng,Owens Tonie,Johnson Abigail,Duffy Elizabeth A
Critical care nursing quarterly
As the progress of critical care medicine has improved the survival rate of critically ill patients, comorbidities and long-term health care have attracted people's attention. The terms "post-intensive care syndrome" (PICS) and "PICS-family" (PICS-F) have been used in non-neurocritical care populations, which are characterized by the cognitive, psychiatric, and physical sequelae associated with intensive care hospitalization of survivors and their families. An intensive care unit (ICU) diary authored by the patient's family members may alleviate the psychological distress of the patient and his or her family. This quality improvement project focused on the development and implementation of the pediatric intensive care unit (PICU) diary in the pediatric critical care setting. The project aims to evaluate the feasibility and the potential efficacy of the PICU diary, measured through parental acceptance and satisfaction. Seventeen families of critically ill children admitted to the PICU received the PICU diary during the implementation period. Twenty-four parents completed the weekly follow-up, and 15 subsequently completed the diary entry evaluation. The use of the diary in the PICU setting is feasible and considered beneficial by families of critically ill children.
COVID-19: ICU delirium management during SARS-CoV-2 pandemic.
Kotfis Katarzyna,Williams Roberson Shawniqua,Wilson Jo Ellen,Dabrowski Wojciech,Pun Brenda T,Ely E Wesley
Critical care (London, England)
The novel coronavirus, SARS-CoV-2-causing Coronavirus Disease 19 (COVID-19), emerged as a public health threat in December 2019 and was declared a pandemic by the World Health Organization in March 2020. Delirium, a dangerous untoward prognostic development, serves as a barometer of systemic injury in critical illness. The early reports of 25% encephalopathy from China are likely a gross underestimation, which we know occurs whenever delirium is not monitored with a valid tool. Indeed, patients with COVID-19 are at accelerated risk for delirium due to at least seven factors including (1) direct central nervous system (CNS) invasion, (2) induction of CNS inflammatory mediators, (3) secondary effect of other organ system failure, (4) effect of sedative strategies, (5) prolonged mechanical ventilation time, (6) immobilization, and (7) other needed but unfortunate environmental factors including social isolation and quarantine without family. Given early insights into the pathobiology of the virus, as well as the emerging interventions utilized to treat the critically ill patients, delirium prevention and management will prove exceedingly challenging, especially in the intensive care unit (ICU). The main focus during the COVID-19 pandemic lies within organizational issues, i.e., lack of ventilators, shortage of personal protection equipment, resource allocation, prioritization of limited mechanical ventilation options, and end-of-life care. However, the standard of care for ICU patients, including delirium management, must remain the highest quality possible with an eye towards long-term survival and minimization of issues related to post-intensive care syndrome (PICS). This article discusses how ICU professionals (e.g., physicians, nurses, physiotherapists, pharmacologists) can use our knowledge and resources to limit the burden of delirium on patients by reducing modifiable risk factors despite the imposed heavy workload and difficult clinical challenges posed by the pandemic.
Development of an ICU discharge instrument predicting psychological morbidity: a multinational study.
Milton A,Schandl A,Soliman I W,Meijers K,van den Boogaard M,Larsson I M,Brorsson C,Östberg U,Oxenbøll-Collet M,Savilampi J,Paskins S,Bottai M,Sackey P V
Intensive care medicine
PURPOSE:To develop an instrument for use at ICU discharge for prediction of psychological problems in ICU survivors. METHODS:Multinational, prospective cohort study in ten general ICUs in secondary and tertiary care hospitals in Sweden, Denmark and the Netherlands. Adult patients with an ICU stay ≥ 12 h were eligible for inclusion. Patients in need of neurointensive care, with documented cognitive impairment, unable to communicate in the local language, without a home address or with more than one limitation of therapy were excluded. Primary outcome was psychological morbidity 3 months after ICU discharge, defined as Hospital Anxiety and Depression Scale (HADS) subscale score ≥ 11 or Post-traumatic Stress Symptoms Checklist-14 (PTSS-14) part B score > 45. RESULTS:A total of 572 patients were included and 78% of patients alive at follow-up responded to questionnaires. Twenty percent were classified as having psychological problems post-ICU. Of 18 potential risk factors, four were included in the final prediction model after multivariable logistic regression analysis: symptoms of depression [odds ratio (OR) 1.29, 95% confidence interval (CI) 1.10-1.50], traumatic memories (OR 1.44, 95% CI 1.13-1.82), lack of social support (OR 3.28, 95% CI 1.47-7.32) and age (age-dependent OR, peak risk at age 49-65 years). The area under the receiver operating characteristics curve (AUC) for the instrument was 0.76 (95% CI 0.70-0.81). CONCLUSIONS:We developed an instrument to predict individual patients' risk for psychological problems 3 months post-ICU, http://www.imm.ki.se/biostatistics/calculators/psychmorb/ . The instrument can be used for triage of patients for psychological ICU follow-up. TRIAL REGISTRATION:The study was registered at clinicaltrials.gov, NCT02679157.
Post-intensive care syndrome: Screening and management in primary care.
Berger Pierre,Braude David
Australian journal of general practice
BACKGROUND:Post-intensive care syndrome (PICS) affects as many as 50% of intensive care unit (ICU) survivors, and symptoms can persist for months to years. When psychological symptoms are experienced by patients' loved ones, this is termed PICS-family (PICS-F). Patients with these syndromes represent a frequently underrecognised and suboptimally managed cohort. OBJECTIVE:The aim of this article is to outline the key aspects of screening and primary care management, providing an evidence-based framework for general practitioners (GPs). DISCUSSION:PICS screening is not well defined. The breadth of symptoms, along with the absence of a national consensus, renders in-depth assessment a significant undertaking. Community management relies on a coordinated effort from the whole multidisciplinary team, spearheaded by the GP, and focuses on three key areas: 'information and education', 'assessment and therapy' and 'personal support'. Collaboration between key stakeholders is needed to improve outcomes in this hitherto underrecognised patient population.
Approaches to Addressing Post-Intensive Care Syndrome among Intensive Care Unit Survivors. A Narrative Review.
Brown Samuel M,Bose Somnath,Banner-Goodspeed Valerie,Beesley Sarah J,Dinglas Victor D,Hopkins Ramona O,Jackson James C,Mir-Kasimov Mustafa,Needham Dale M,Sevin Carla M,
Annals of the American Thoracic Society
Critical illness can be lethal and devastating to survivors. Improvements in acute care have increased the number of intensive care unit (ICU) survivors. These survivors confront a range of new or worsened health states that collectively are commonly denominated post-intensive care syndrome (PICS). These problems include physical, cognitive, psychological, and existential aspects, among others. Burgeoning interest in improving long-term outcomes for ICU survivors has driven an array of potential interventions to improve outcomes associated with PICS. To date, the most promising interventions appear to relate to very early physical rehabilitation. Late interventions within aftercare and recovery clinics have yielded mixed results, although experience in heart failure programs suggests the possibility that very early case management interventions may help improve intermediate-term outcomes, including mortality and hospital readmission. Predictive models have tended to underperform, complicating study design and clinical referral. The complexity of the health states associated with PICS suggests that careful and rigorous evaluation of multidisciplinary, multimodality interventions-tied to the specific conditions of interest-will be required to address these important problems.
[Post-Intensive Care Syndrome in Intensive Care Patients and Their Families].
Hu li za zhi The journal of nursing
The population of survivors of critical illness has increased with advancements in medicine and technology. However, many patients and their families experience post-intensive care syndromes after discharge from intensive care units (ICUs) due to the comorbidities and side-effects of severe illnesses and related treatments. The problems faced by these survivors are mainly physical symptoms, cognitive disorders, and psychological problems (including anxiety, depression, and traumatic stress disorder). Moreover, patient family members frequently experience psychological problems as well. This article introduces the post-intensive care syndromes (PICS) of survivors and their families; describe the physical symptoms, risk factors, and prevention strategies related to PICS; and primary instruments currently used to measure PICS. The authors hope to provide intensive care health staff with the knowledge necessary to implement preventive strategies for patients as early as possible during their ICU stay to improve the quality of intensive care.
[Progress in pathophysiology and integrated traditional Chinese and Western medicine of post-intensive care syndrome].
Wang Zheng,Yang Luping,Qin Yidan,Wang Yu
Zhonghua wei zhong bing ji jiu yi xue
With the continuous improvement of treatment ability in intensive care unit (ICU), many critically ill and complex patients have survived due to the development of technology. However, most of them suffer from the psychological and physiological problems of post-intensive care syndrome (PICS). Therefore, the early identification and prevention of PICS is particularly critical. We should understand the pathophysiological mechanism of PICS, strictly implement ABCDEFG bundle management measures [including airway management (A), breath (B), reasonable analgesia and sedation treatment (C), prevention of delirium (D), early rehabilitation (E), family engagement (F), good communication (G)] during ICU hospitalization, and pay attention to reasonable nutritional support, optimizing blood glucose management, providing positive psychological intervention and support to patients through family members' encouragement and accompanying, ICU diary and other forms, following up the health status of patients transferred out/discharged from ICU, providing multi-disciplinary and professional continuing medical services, finding the entry point and timing of traditional Chinese medicine intervention, and giving full play to the advantages of integrated traditional Chinese and Western medicine treatment, which can improve the quality of life of patients. This article reviews the pathophysiological mechanism, risk factors, prevention and management measures, traditional Chinese medicine syndrome differentiation and treatment of PICS, in order to improve the early identification, diagnosis and treatment of critical patients with PICS, and improve the prognosis of patients.
Early Post-Intensive Care Syndrome among Older Adult Sepsis Survivors Receiving Home Care.
Riegel Barbara,Huang Liming,Mikkelsen Mark E,Kutney-Lee Ann,Hanlon Alexandra L,Murtaugh Christopher M,Bowles Kathryn H
Journal of the American Geriatrics Society
BACKGROUND/OBJECTIVES:New or worsened disabilities in functional, cognitive, or mental health following an intensive care unit (ICU) stay are referred to as post-intensive care syndrome (PICS). PICS has not been described in older adults receiving home care. Our aim was to examine the relationship between length of ICU stay and PICS among older adults receiving home care. We expected that patients in the ICU for 3 days or longer would demonstrate significantly more disability in all three domains on follow-up than those not in the ICU. A secondary aim was to identify patient characteristics increasing the odds of disability. DESIGN:Retrospective cohort study. SETTING:Hospitalization for sepsis in the United States. PARTICIPANTS:A total of 21 520 Medicare patients receiving home care and reassessed a median of 1 day (interquartile range 1-2 d) after hospital discharge. MEASUREMENTS:PICS was defined as a decline or worsening in one or more of 16 indicators tested before and after hospitalization using OASIS (Home Health Outcome and Assessment Information Set) and Medicare claims data. RESULTS:The sample was predominantly female and white. All had sepsis, and most (81.8%) had severe sepsis. In adjusted models, an ICU stay of 3 days or longer, compared with no ICU stay, increased the odds of physical disability. Overall, the declines were modest and found in specific activities of daily living (16% for feeding and lower body dressing to 26% for oral medicine management). No changes were identified in cognition or mental health. Significant determinants of new or worsened physical disabilities were sepsis severity, older age, depression, frailty, and dementia. CONCLUSION:Older adults receiving home care who develop sepsis and are in an ICU for 3 days or longer are likely to develop new or worsened physical disabilities. Whether these disabilities remain after the early postdischarge phase requires further study. J Am Geriatr Soc 67:520-526, 2019.
MONITOR-IC study, a mixed methods prospective multicentre controlled cohort study assessing 5-year outcomes of ICU survivors and related healthcare costs: a study protocol.
Geense Wytske,Zegers Marieke,Vermeulen Hester,van den Boogaard Mark,van der Hoeven Johannes
INTRODUCTION:Due to advances in critical care medicine, more patients survive their critical illness. However, intensive care unit (ICU) survivors often experience long-term physical, cognitive and mental problems, summarised as post-intensive care syndrome (PICS), impacting their health-related quality of life (HRQoL). In what frequency PICS occurs, and to what extent this influences ICU survivors' HRQoL, is mostly unknown. The aims of this study are therefore to study the: (1) 5-year patient outcomes, (2) predictors for PICS, (3) ratio between HRQoL of ICU survivors and healthcare-related costs, and (4) care and support needs. METHODS:The MONITOR-IC study is a multicentre prospective controlled cohort study, carried out in ICUs in four Dutch hospitals. Patients will be included between July 2016 and July 2021 and followed for 5 years. We estimated to include 12000 ICU patients. Outcomes are the HRQoL, physical, cognitive and mental symptoms, ICU survivors' care and support needs, healthcare use and related costs. A control cohort of otherwise seriously ill patients will be assembled to compare long-term patient-reported outcomes. We will use a mixed methods design, including questionnaires, medical data from patient records, cost data from health insurance companies and interviews with patients and family members. ETHICS AND DISSEMINATION:Insights from this study will be used to inform ICU patients and their family members about long-term consequences of ICU care, and to develop prediction and screening instruments to detect patients at risk for PICS. Subsequently, tailored interventions can be developed and implemented to prevent and mitigate long-term consequences. Additionally, insights into the ratio between HRQoL of ICU patients and related healthcare costs during 5 years after ICU admission can be used to discuss the added value of ICU care from a community perspective. The study has been approved by the research ethics committee of the Radboud University Medical Center (2016-2724). CLINICAL TRIAL REGISTRATION:NCT03246334.
Virtual reality for relatives of ICU patients to improve psychological sequelae: study protocol for a multicentre, randomised controlled trial.
Vlake Johan H,van Bommel Jasper,Wils Evert-Jan,Korevaar Tim,Hellemons Merel E,Klijn Eva,Schut Anna Fc,Labout Joost Am,Van Bavel Marten P,van Mol Margo Mc,Gommers Diederik,van Genderen Michel E
INTRODUCTION:Intensive care unit (ICU) admission of a relative might lead to psychological distress and complicated grief (post-intensive care syndrome-family; PICS-F). Evidence suggests that increased distress during ICU stay increases risk of PICS-F, resulting in difficulty returning to their normal lives after the ICU experience. Effective interventions to improve PICS-F are currently lacking. In the present trial, we hypothesised that information provision using ICU-specific Virtual Reality for Family members/relatives (ICU-VR-F) may improve understanding of the ICU and subsequently improve psychological well-being and quality of life in relatives of patients admitted to the ICU. METHODS AND ANALYSIS:This multicentre, clustered randomised controlled trial will be conducted from January to December 2021 in the mixed medical-surgical ICUs of four hospitals in Rotterdam, the Netherlands. We aim to include adult relatives of 160 ICU patients with an expected ICU length of stay over 72 hours. Participants will be randomised clustered per patient in a 1:1 ratio to either the intervention or control group. Participants allocated to the intervention group will receive ICU-VR-F, an information video that can be watched in VR, while the control group will receive usual care. Initiation of ICU-VR-F will be during their hospital visit unless participants cannot visit the hospital due to COVID-19 regulations, then VR can be watched digitally at home. The primary objective is to study the effect of ICU-VR-F on psychological well-being and quality of life up to 6 months after the patients' ICU discharge. The secondary outcome is the degree of understanding of ICU treatment and ICU modalities. ETHICS AND DISSEMINATION:The Medical Ethics Committee of the Erasmus Medical Centre, Rotterdam, the Netherlands, approved the study and local approval was obtained from each participating centre (NL73670.078.20). Our findings will be disseminated by presentation of the results at (inter)national conferences and publication in scientific, peer-reviewed journals. TRIAL REGISTRATION NUMBER:Netherlands Trial Register (TrialRegister.nl, NL9220).
Predicting Coma Trajectories: The Impact of Bias and Noise on Shared Decisions.
Wijdicks Eelco F M,Hwang David Y
Coma trajectories are characterized by quick awakening or protracted awakening. Outcome is bookended by restored functionality or permanent cognitively and physically debilitated states. Given the stakes, prognostication cannot be easily questioned as a judgment call, and a scientific underpinning is elemental. Conventional wisdom in determining coma-outcome trajectories posits that (1) predictive models are better than personal experiences, (2) self-fulfilling prophesy is unchecked and driven by nihilism, with little regard for prior probability outcomes, and (3) recovery is impacted by patients' prior wishes and preexisting medical conditions-but also by what families are told about the patient's state and anticipated clinical course. Moreover, a predicted good outcome can be offset by a major subsequent complication, or a predicted poor outcome can be offset by aggressive care. This article examines some of these concepts, including how we decide on aggressiveness of care, how we judge quality of life, and the impact on outcome. Most patients who awaken quickly do well and can resume their pretrauma injury lives. In worse off, slow-to-awaken patients, outcomes are a mixed bag of limited innate resilience, depleted cognitive and physical reserves, and adjusted quality of life. Bias and noise are factors not easily measured in outcome prediction, but their influence on recovery trajectories raises some troubling issues.
Mental Health Interventions to Improve Psychological Outcomes in Informal Caregivers of Critically Ill Patients: A Systematic Review and Meta-Analysis.
Cherak Stephana J,Rosgen Brianna K,Amarbayan Mungunzul,Wollny Krista,Doig Christopher J,Patten Scott B,Stelfox Henry T,Fiest Kirsten M
Critical care medicine
OBJECTIVES:Determine effect of mental health interventions on psychologic outcomes in informal caregivers of critically ill patients. DATA SOURCES:Searches conducted in MEDLINE, Embase, and other databases from inception to October 31, 2019. STUDY SELECTION:Interventions for informal caregivers of critically ill patients in adult ICU, PICU, or neonatal ICU. DATA EXTRACTION:Two independent, blinded reviewers screened citations and extracted data. Random-effects models with inverse variance weighting pooled outcome data when suitable. Psychologic outcomes categorized: 1) negative (anxiety, depression, post-traumatic stress disorder, distress, and burden) or 2) positive (courage, humanity, justice, transcendence, temperance, and wisdom and knowledge). Stratification according to intervention type and patient population was performed. DATA SYNTHESIS:Of 11,201 studies, 102 interventional trials were included (n = 12,676 informal caregivers). Interventions targeted caregiver experience (n = 58), role (n = 6), or support (n = 38). Meta-analysis (56 randomized controlled trials; n = 22 [39%] in adult ICUs; n = 34 [61%] in neonatal ICU or PICU) demonstrated reduced anxiety (ratio of means = 0.92; 95% CI, 0.87-0.97) and depression (ratio of means = 0.83; 95% CI, 0.69-0.99), but not post-traumatic stress disorder (ratio of means = 0.91; 95% CI, 0.80-1.04) or distress (ratio of means = 1.01; 95% CI, 0.95-1.07) among informal caregivers randomized to mental health interventions compared with controls within 3 months post-ICU discharge. Increased humanity (ratio of means = 1.11; 95% CI, 1.07-1.15), transcendence (ratio of means = 1.11; 95% CI, 1.07-1.15), and caregiver burden (ratio of means = 1.08; 95% CI, 1.05-1.12) were observed. No significant effects of mental health interventions observed after 3 months postdischarge. CONCLUSIONS:Mental health interventions for caregivers of critically ill patients improved short-term anxiety, depression, humanity, and transcendence while increasing burden. Clinicians should consider short-term prescriptions of mental health interventions to informal caregivers of critically ill patients with capacity to manage interventions.
Respiratory Therapists in an ICU Recovery Clinic: Two Institutional Experiences and Review of the Literature.
Bellinghausen Amy L,Butcher Brad W,Ho Le Tm,Nestor Alison,Morrell Joseph,Chu Frank,Owens Robert L
Post-intensive care syndrome is an increasingly recognized complication of critical illness, with patients reporting new problems in physical, mental health and/or psychosocial, and cognitive function for months to years after their acute illness. As a way of diagnosing and treating post-intensive care syndrome, many centers around the world have established ICU recovery clinics, which take a multidisciplinary approach to care after the ICU. Dyspnea and pulmonary dysfunction are frequently encountered concerns in the post-ICU population. Despite this, few ICU recovery clinics have described how respiratory therapists (RTs) can contribute to treating these symptoms. We reviewed the literature with regard to the roles of an RT in post-ICU follow-up, described our institutional experiences with having RTs as part of our ICU recovery clinics, and identified additional ways that RTs might contribute to a post-intensive care syndrome diagnosis and treatment. Although RTs can provide invaluable experience and contributions to an ICU recovery clinic, there are few articles in the published literature on the ways in which this can be accomplished. We, therefore, provide analogies to other multidisciplinary clinic models as well as our own experiences. Future studies should focus on examining the impact of respiratory therapy diagnostic testing and interventions in the ICU recovery clinic on both patient and provider outcomes.
Post-intensive care syndrome: its pathophysiology, prevention, and future directions.
Inoue Shigeaki,Hatakeyama Junji,Kondo Yutaka,Hifumi Toru,Sakuramoto Hideaki,Kawasaki Tatsuya,Taito Shunsuke,Nakamura Kensuke,Unoki Takeshi,Kawai Yusuke,Kenmotsu Yuji,Saito Masafumi,Yamakawa Kazuma,Nishida Osamu
Acute medicine & surgery
Expanding elderly populations are a major social challenge in advanced countries worldwide and have led to a rapid increase in the number of elderly patients in intensive care units (ICUs). Innovative advances in medical technology have enabled lifesaving of patients in ICUs, but there remain various problems to improve their long-term prognoses. Post-intensive care syndrome (PICS) refers to physical, cognition, and mental impairments that occur during ICU stay, after ICU discharge or hospital discharge, as well as the long-term prognosis of ICU patients. Its concept also applies to pediatric patients (PICS-p) and the mental status of their family (PICS-F). Intensive care unit-acquired weakness, a syndrome characterized by acute symmetrical limb muscle weakness after ICU admission, belongs to physical impairments in three domains of PICS. Prevention of PICS requires performance of the ABCDEFGH bundle, which incorporates the prevention of delirium, early rehabilitation, family intervention, and follow-up from the time of ICU admission to the time of discharge. Diary, nutrition, nursing care, and environmental management for healing are also important in the prevention of PICS. This review outlines the pathophysiology, prevention, and future directions of PICS.
Post-Intensive Care Syndrome in Children: A Concept Analysis.
Journal of pediatric nursing
PROBLEM:Post-intensive care syndrome in paediatrics (PICS-p) is a term used to describe newly acquired or worsened impairment in one or more aspects of a child's physical, psychological, cognitive, and social functioning after discharge from the paediatric intensive care unit (PICU). However, consensus, conceptual insights, and assessment guidance are lacking for this syndrome. Therefore, this analysis aimed to define the concept of PICS-p to help practitioners and researchers understand the syndrome in detail using the Walker and Avant approach. ELIGIBILITY CRITERIA:We reviewed studies retrieved from several databases, namely PubMed, Google Scholar, Web of Science, Ovid, ScienceDirect, and the Springer database, using the following keywords: 'post-intensive care syndrome', 'PICU', 'children', 'PICS-p', and 'concept analysis'. Both quantitative and qualitative studies on PICS-p were included in the search. The articles were limited to those published up to November 21, 2020. SAMPLE:Of the 762 publications selected, 24 publications met the inclusion criteria. RESULTS:PICS-p is defined on the basis of the following aspects: (1) Physical dysfunction; (2) Cognitive dysfunction; (3) Psychological dysfunction; and (4) Social dysfunction. CONCLUSION:With the increasing success rate of PICU treatment, reduced case fatality is no longer the only outcome of critical illness in children. The long-term outcomes in children discharged from hospitals have attracted attention from families, hospitals, and communities. IMPLICATIONS:A clear definition of PICS-p will help medical staff understand PICS-p in detail and provide a theoretical basis for the diagnosis and treatment of this syndrome.
High occurrence of postintensive care syndrome identified in surgical ICU survivors after implementation of a multidisciplinary clinic.
Bottom-Tanzer Samantha F,Poyant Janelle O,Louzada Maria T,Ahmed Sana E,Boudouvas Abbey,Poon Eileen,Hojman Horacio M,Bugaev Nikolay,Johnson Benjamin P,Van Kirk Anna Lisa,Daniel Eryn,Emoff Caroline,Mahoney Eric J
The journal of trauma and acute care surgery
BACKGROUND:Postintensive care syndrome (PICS) has been identified in a large proportion of medical intensive care unit survivors; however, the occurrence surgical intensive care unit (SICU) survivors is unknown. We implemented a multidisciplinary critical care outpatient clinic (CCOC) to identify the occurrence of PICS in SICU survivors. METHODS:Seventy acute care surgery and trauma patients, 18 years or older, who remained in the SICU for 72 hours or longer at a Level I trauma center were seen in CCOC at 2 weeks, 12 weeks, and 24 weeks after hospital discharge. The CCOC staffing included a nurse coordinator, social worker, critical care pharmacist, physical therapist, and acute care surgeon who identified PICS sequelae in their respective specialties by clinical criteria and screening questionnaires. RESULTS:Of 82 eligible patients, 70 (85.4%) were seen at least once for 116 total visits. Forty-three (61.4%) patients suffered traumatic injuries and 27 (38.6%) underwent emergent general surgery. Sixty-seven (95.7%) demonstrated at least one PICS criterion. Over all visits, 26 (37.1%) patients presented with one PICS criterion, 24 (34.3%) patients with two, and 17 (24.3%) with three. Cognitive impairment was observed in 29 (41.4%) patients, psychiatric in 30 (42.9%), and physical symptoms in 65 (92.9%). Activity Measure for Post-Acute Care scores improved from severe impairment at admission to full function by 12 weeks postdischarge, yet 6 Minute Walk Test scores remained below age-matched references through all visits. Patients expressed mild to moderate depression based on Patient Health Questionnaire-9 scores. A medication reconciliation was completed at 96.5% (112/116) of the visits with 116 total medication recommendations. By 24 weeks following discharge, only 26.4% (14/53) of previously employed patients had resumed work. CONCLUSION:Through the successful implementation of a multidisciplinary CCOC, this study identifies an exorbitant rate of PICS among SICU survivors. LEVEL OF EVIDENCE:Therapeutic/epidemiological, level III.
Experiences, opinions and expectations of health care providers towards an intensive care unit follow-up clinic: Qualitative study and online survey.
Rohr Magdalena,Weiß Annette,Bein Thomas,Bernardi Christine,Brandstetter Susanne,Drewitz Karl Philipp,Fisser Christoph,Loss Julika,Malfertheiner Maximilian,Apfelbacher Christian
Intensive & critical care nursing
OBJECTIVES:Independent of the underlying disease, intensive care unit survivors often suffer from cognitive, physical and mental impairments, also known as post-intensive care syndrome (PICS). Specific follow-up services are recommended for these patients. This study aims to capture the perspectives of health care providers on the development of the first intensive care unit follow-up-clinic in Germany. RESEARCH METHODOLOGY:A qualitative study with six focus groups (n = 41) and six expert interviews, followed by a quantitative survey was conducted, involving nine different professions. Qualitative and quantitative data were analysed using thematic analysis and descriptive statistics, respectively. FINDINGS:Participants described aftercare of former intensive care unit patients as complex and appreciated the idea of an intensive care unit follow-up clinic to improve continuity of care and multidisciplinary collaboration. The favoured model combined diagnostics and targeted referral of patients to specialists and therapists with the provision of information. In the survey, participants disagreed on how to implement this referral system but agreed that assessments should be multidimensional. CONCLUSION:The necessity of and important criteria for the design of an intensive care unit follow-up clinic were identified. We will integrate these data with further evidence to develop a concept for a complex intervention.
Implications for post critical illness trial design: sub-phenotyping trajectories of functional recovery among sepsis survivors.
Puthucheary Zudin A,Gensichen Jochen S,Cakiroglu Aylin S,Cashmore Richard,Edbrooke Lara,Heintze Christoph,Neumann Konrad,Wollersheim Tobias,Denehy Linda,Schmidt Konrad F R
Critical care (London, England)
BACKGROUND:Patients who survive critical illness suffer from a significant physical disability. The impact of rehabilitation strategies on health-related quality of life is inconsistent, with population heterogeneity cited as one potential confounder. This secondary analysis aimed to (1) examine trajectories of functional recovery in critically ill patients to delineate sub-phenotypes and (2) to assess differences between these cohorts in both clinical characteristics and clinimetric properties of physical function assessment tools. METHODS:Two hundred ninety-one adult sepsis survivors were followed-up for 24 months by telephone interviews. Physical function was assessed using the Physical Component Score (PCS) of the Short Form-36 Questionnaire (SF-36) and Activities of Daily Living and the Extra Short Musculoskeletal Function Assessment (XSFMA-F/B). Longitudinal trajectories were clustered by factor analysis. Logistical regression analyses were applied to patient characteristics potentially determining cluster allocation. Responsiveness, floor and ceiling effects and concurrent validity were assessed within clusters. RESULTS:One hundred fifty-nine patients completed 24 months of follow-up, presenting overall low PCS scores. Two distinct sub-cohorts were identified, exhibiting complete recovery or persistent impairment. A third sub-cohort could not be classified into either trajectory. Age, education level and number of co-morbidities were independent determinants of poor recovery (AUROC 0.743 ((95%CI 0.659-0.826), p < 0.001). Those with complete recovery trajectories demonstrated high levels of ceiling effects in physical function (PF) (15%), role physical (RP) (45%) and body pain (BP) (57%) domains of the SF-36. Those with persistent impairment demonstrated high levels of floor effects in the same domains: PF (21%), RP (71%) and BP (12%). The PF domain demonstrated high responsiveness between ICU discharge and at 6 months and was predictive of a persistent impairment trajectory (AUROC 0.859 (95%CI 0.804-0.914), p < 0.001). CONCLUSIONS:Within sepsis survivors, two distinct recovery trajectories of physical recovery were demonstrated. Older patients with more co-morbidities and lower educational achievements were more likely to have a persistent physical impairment trajectory. In regard to trajectory prediction, the PF score of the SF-36 was more responsive than the PCS and could be considered for primary outcomes. Future trials should consider adaptive trial designs that can deal with non-responders or sub-cohort specific outcome measures more effectively.
Anxiety, Depression and Post Traumatic Stress Disorder after critical illness: a UK-wide prospective cohort study.
Hatch Robert,Young Duncan,Barber Vicki,Griffiths John,Harrison David A,Watkinson Peter
Critical care (London, England)
BACKGROUND:Survivors of intensive care are known to be at increased risk of developing longer-term psychopathology issues. We present a large UK multicentre study assessing the anxiety, depression and post-traumatic stress disorder (PTSD) caseness in the first year following discharge from an intensive care unit (ICU). METHODS:Design: prospective multicentre follow-up study of survivors of ICU in the UK. SETTING:patients from 26 ICUs in the UK. INCLUSION CRITERIA:patients who had received at least 24 h of level 3 ICU care and were 16 years of age or older. INTERVENTIONS:postal follow up: Hospital Anxiety and Depression Score (HADS) and the Post-Traumatic Stress Disorder (PTSD) Check List-Civilian (PCL-C) at 3 and 12 months following discharge from ICU. MAIN OUTCOME MEASURE:caseness of anxiety, depression and PTSD, 2-year survival. RESULTS:In total, 21,633 patients admitted to ICU were included in the study. Postal questionnaires were sent to 13,155 survivors; of these 38% (4943/13155) responded and 55% (2731/4943) of respondents passed thresholds for one or more condition at 3 or 12 months following discharge. Caseness prevalence was 46%, 40% and 22% for anxiety, depression and PTSD respectively; 18% (870/4943 patients) met the caseness threshold for all three psychological conditions. Patients with symptoms of depression were 47% more likely to die during the first 2 years after discharge from ICU than those without (HR 1.47, CI 1.19-1.80). CONCLUSIONS:Over half of those who respond to postal questionnaire following treatment on ICU in the UK reported significant symptoms of anxiety, depression or PTSD. When symptoms of one psychological disorder are present, there is a 65% chance they will co-occur with symptoms of one of the other two disorders. Depression following critical illness is associated with an increased mortality risk in the first 2 years following discharge from ICU. TRIAL REGISTRATION:ISRCTN Registry, ISRCTN69112866 . Registered on 2 May 2006.
Impact of post-traumatic stress symptoms on the health-related quality of life in a cohort study with chronically critically ill patients and their partners: age matters.
Wintermann Gloria-Beatrice,Petrowski Katja,Weidner Kerstin,Strauß Bernhard,Rosendahl Jenny
Critical care (London, England)
BACKGROUND:Survivors of an acute critical illness with continuing organ dysfunction and uncontrolled inflammatory responses are prone to become chronically critically ill. As mental sequelae, a post-traumatic stress disorder and an associated decrease in the health-related quality of life (QoL) may occur, not only in the patients but also in their partners. Currently, research on long-term mental distress in chronically critically ill patient-partner dyads, using appropriate dyadic analysis strategies (patients and partners being measured and linked on the same variables) and controlling for contextual factors, is lacking. METHODS:The present study investigates the interdependence of post-traumatic stress symptoms (PTSS) and the health-related QoL in n = 70 dyads of chronically critically ill patients and their partners, using the Actor-Partner-Interdependence Model (APIM) under consideration of contextual factors (age, gender, length of partnership). The Post-traumatic Stress Scale (PTSS-10) and Euro-Quality of Life (EQ-5D-3L) were applied in both the patients and their partners, within up to 6 months after the transfer from acute care ICU to post-acute ICU. RESULTS:Clinically relevant post-traumatic stress symptoms were reported by 17.1% of the patients and 18.6% of the partners. Both the chronically critically ill patients and their partners with more severe post-traumatic stress symptoms also showed a decreased health-related QoL. The latter was more pronounced in male partners compared to female partners or female patients. In younger partners (≤ 57 years), higher values of post-traumatic stress symptoms were associated with a decreased QoL in the patients. CONCLUSIONS:Mental health screening and psychotherapeutic treatment options should be offered to both the chronically critically ill patients and their partners. Future research is required to address the special needs of younger patient-partner dyads, following protracted ICU treatment. TRIAL REGISTRATION:German Clinical Trials Register No. DRKS00003386 . Registered 13 November 2011.
Historic review of long-term outcomes research.
Current opinion in critical care
PURPOSE OF REVIEW:This review summarizes the results from long-term intensive care outcome research over the past 50 years. Key findings from early studies are reflected in citations of contemporary research. RECENT FINDINGS:The postintensive care syndrome (PICS) is a multifaceted entity of residual disability and complications burdening survivors of critical illness. Some interventions applied early in the history of outcomes research have now been confirmed as effective in counteracting specific PICS components. SUMMARY:Interest in patient-centred outcomes has been present since the beginning of modern intensive care. Findings from early long-term studies remain valid even in the face of contemporary large registries that facilitate follow-up of larger cohorts. A further understanding of the mechanisms leading to experienced physical and psychological impairment of PICS will be essential to the design of future intervention trials.
Follow-up services for improving long-term outcomes in intensive care unit (ICU) survivors.
The Cochrane database of systematic reviews
BACKGROUND:The intensive care unit (ICU) stay has been linked with a number of physical and psychological sequelae, known collectively as post-intensive care syndrome (PICS). Specific ICU follow-up services are relatively recent developments in health systems, and may have the potential to address PICS through targeting unmet health needs arising from the experience of the ICU stay. There is currently no single accepted model of follow-up service and current aftercare programmes encompass a variety of interventions and materials. There is uncertain evidence about whether follow-up services effectively address PICS, and this review assesses this. OBJECTIVES:Our main objective was to assess the effectiveness of follow-up services for ICU survivors that aim to identify and address unmet health needs related to the ICU period. We aimed to assess effectiveness in relation to health-related quality of life (HRQoL), mortality, depression and anxiety, post-traumatic stress disorder (PTSD), physical function, cognitive function, ability to return to work or education and adverse effects.Our secondary objectives were to examine different models of follow-up services. We aimed to explore: the effectiveness of service organisation (physician- versus nurse-led, face-to-face versus remote, timing of follow-up service); differences related to country (high-income versus low- and middle-income countries); and effect of delirium, which can subsequently affect cognitive function, and the effect of follow-up services may differ for these participants. SEARCH METHODS:We searched CENTRAL, MEDLINE, Embase and CINAHL on 7 November 2017. We searched clinical trials registers for ongoing studies, and conducted backward and forward citation searching of relevant articles. SELECTION CRITERIA:We included randomised and non-randomised studies with adult participants, who had been discharged from hospital following an ICU stay. We included studies that compared an ICU follow-up service using a structured programme and co-ordinated by a healthcare professional versus no follow-up service or standard care. DATA COLLECTION AND ANALYSIS:Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias, and synthesised findings. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS:We included five studies (four randomised studies; one non-randomised study), for a total of 1707 participants who were ICU survivors with a range of illness severities and conditions. Follow-up services were led by nurses in four studies or a multidisciplinary team in one study. They included face-to-face consultations at home or in a clinic, or telephone consultations or both. Each study included at least one consultation (weekly, monthly, or six-monthly), and two studies had up to eight consultations. Although the design of follow-up service consultations differed in each study, we noted that each service included assessment of participants' needs with referrals to specialist support if required.It was not feasible to blind healthcare professionals or participants to the intervention and we did not know whether this may have introduced performance bias. We noted baseline differences (two studies), and services included additional resources (two studies), which may have influenced results, and one non-randomised study had high risk of selection bias.We did not combine data from randomised studies with data from one non-randomised study. Follow-up services for improving long-term outcomes in ICU survivors may make little or no difference to HRQoL at 12 months (standardised mean difference (SMD) -0.0, 95% confidence interval (CI) -0.1 to 0.1; 1 study; 286 participants; low-certainty evidence). We found moderate-certainty evidence from five studies that they probably also make little or no difference to all-cause mortality up to 12 months after ICU discharge (RR 0.96, 95% CI 0.76 to 1.22; 4 studies; 1289 participants; and in one non-randomised study 79/259 deaths in the intervention group, and 46/151 in the control group) and low-certainty evidence from four studies that they may make little or no difference to PTSD (SMD -0.05, 95% CI -0.19 to 0.10, 703 participants, 3 studies; and one non-randomised study reported less chance of PTSD when a follow-up service was used).It is uncertain whether using a follow-up service reduces depression and anxiety (3 studies; 843 participants), physical function (4 studies; 1297 participants), cognitive function (4 studies; 1297 participants), or increases the ability to return to work or education (1 study; 386 participants), because the certainty of this evidence is very low. No studies measured adverse effects.We could not assess our secondary objectives because we found insufficient studies to justify subgroup analysis. AUTHORS' CONCLUSIONS:We found insufficient evidence, from a limited number of studies, to determine whether ICU follow-up services are effective in identifying and addressing the unmet health needs of ICU survivors. We found five ongoing studies which are not included in this review; these ongoing studies may increase our certainty in the effect in future updates. Because of limited data, we were unable to explore whether one design of follow-up service is preferable to another, or whether a service is more effective for some people than others, and we anticipate that future studies may also vary in design. We propose that future studies are designed with robust methods (for example randomised studies are preferable) and consider only one variable (the follow-up service) compared to standard care; this would increase confidence that the effect is due to the follow-up service rather than concomitant therapies.
Effectiveness of cognitive interventions on cognitive outcomes of adult intensive care unit survivors: A scoping review.
Muradov Olga,Petrovskaya Olga,Papathanassoglou Elizabeth
Australian critical care : official journal of the Confederation of Australian Critical Care Nurses
BACKGROUND:Cognitive impairments have been identified as significant under-recognised negative sequelae of postintensive care syndrome. No treatment guidelines exist for cognitive interventions addressing the devastating consequences of impairments and their potential impact on outcomes of intensive care unit (ICU) survivors. AIM:The aim of the study was to identify all available cognitive interventions and measurable outcomes for the cognitive rehabilitation of adult ICU survivors, as reported in published articles. Secondary aims included to critically synthesise existing evidence in improving adult ICU survivors' cognitive outcomes after ICU discharge and to extract implications for future research. METHODS:A scoping review was conducted based on a rigorous literature search (CINAHL, Embase, MEDLINE, PubMed, SCOPUS, Cochrane Library, and Google Scholar) using predefined keywords. The protocol was based on current guidelines. Eligibility criteria included published (i) experimental and quasi-experimental studies reporting the effects of cognitive interventions on cognitive outcomes of adult critical illness survivors after hospital discharge and (ii) protocols identifying cognitive interventions with predefined cognitive outcome measures. RESULTS:Seven studies were included: three experimental studies, two quasi-experimental studies, and two published protocols. Significant heterogeneity in the type of interventions, outcome measures, and assessment tools was noted. Interventions included variations of goal management training and an integrated multidisciplinary model. The setting, delivery, and duration of interventions varied. Cognitive outcomes included variations of global cognitive function and executive function. Overall, the evidence on the effects of cognitive interventions, as compared with routine care, in improving global cognitive function is inconclusive. More evidence support exists with respect to improving executive function. CONCLUSION:Although various cognitive intervention approaches have shown some positive effects on outcomes of ICU survivors after hospital discharge, the high risk of bias and high heterogeneity across studies preclude conclusions about the most appropriate post-ICU care to rehabilitate cognitive deficits in critical care survivors. This review highlighted a number of methodological limitations that require further investigation.
Plasma HMGB1 levels and physical performance in ICU survivors.
Acta anaesthesiologica Scandinavica
PURPOSE:Physical impairment after critical illness is recognized as a part of the post-intensive care syndrome (PICS). About one third of intensive care unit (ICU) survivors suffer from long-term physical disability, yet the underlying pathophysiological mechanisms remain poorly understood. The pro-inflammatory alarmin, high mobility group box 1 (HMGB1), promotes muscle dysfunction in experimental models, and HMGB1 stays elevated in some patients after ICU discharge. Accordingly, we investigated the relationship between HMGB1 plasma levels and physical performance in ICU survivors. METHODS:Prospective cohort study of 100 ICU survivors from the general ICU at the Karolinska University Hospital, Sweden. Patients returned for follow up at 3 (58 patients) and 6 months (51 patients) after ICU discharge. Blood samples were collected, and a 6-minute walk test (6-MWT), a handgrip-strength test (HST), and a timed-stands test (TST) were performed. RESULTS:Compared to reference values of the different physical tests, 16% of patients underperformed at all tests at 3 months and 12% at 6 months. All test results, except hand-grip strength left, improved significantly over the follow-up period (P < .05). There was no significant association between plasma HMGB1 levels at 3 and 6 months and scores on the three tests (6-MWT, TST, and HST) (P = .50-0.69). CONCLUSION:In this follow-up study of ICU survivors, we found no significant association between plasma HMGB1 levels and physical performance. Additional follow-up studies of HMGB1 plasma levels and muscle function in ICU survivors are still warranted. EDITORIAL COMMENT:HMGB-1, a marker of cell damage and activation, is known to increase in ICU patients. In study participants at 3- to 6-month post-ICU stay, HMGB-1 levels were still elevated, although no association to the primary outcome, physical performance, was found. Mechanisms for failure to recover physical performance post-ICU remain unclear, and investigations into cause of post-intensive care syndrome need to continue. TRIAL REGISTRATIONS:ClinicalTrials.gov identifier NCT02914756.
Implementing an intensive care unit (ICU) diary program at a large academic medical center: Results from a randomized control trial evaluating psychological morbidity associated with critical illness.
Sayde George E,Stefanescu Andrei,Conrad Erich,Nielsen Nathan,Hammer Rachel
General hospital psychiatry
BACKGROUND:Psychological morbidity in both patients and family members related to the intensive care unit (ICU) experience is an often overlooked, and potentially persistent, healthcare problem recognized by the Society of Critical Care Medicine as Post-intensive Care Syndrome (PICS). ICU diaries are an intervention increasingly under study with potential to mitigate ICU-related psychological morbidity, including ICU-related post-traumatic stress disorder (PTSD), depression and anxiety. As we encounter a growing number of ICU survivors, in particular in the wake of the coronavirus pandemic, clinicians must be equipped to understand the severity and prevalence of significant psychiatric complications of critical illness. METHODS:We compared the efficacy of the ICU diary, written by family and healthcare workers during the patient's intensive care course, versus education alone in reducing acute PTSD symptoms after discharge. Patients with an ICU stay >72 h, who were intubated and mechanically ventilated over 24 h, were recruited and randomized to either receive a diary at bedside with psychoeducation or psychoeducation alone. Intervention patients received their ICU diary within the first week of admission into the intensive care unit. Psychological symptom screening with IES-R, PHQ-8, HADS and GAD-7 was conducted at baseline within 1 week of ICU discharge and at weeks 4, 12, and 24 after ICU discharge. Change from baseline in these scores was assessed using Wilcoxon rank sum tests. RESULTS:From September 26, 2017 to September 25, 2018, our team screened 265 patients from the surgical and medical ICUs at a single large academic urban hospital. 60 patients were enrolled and randomized, of which 35 patients completed post-discharge follow-up, (n = 18) in the diary intervention group and (n = 17) in the education-only control group. The control group had a significantly greater decrease in PTSD, hyperarousal, and depression symptoms at week 4 compared to the intervention group. There were no significant differences in other measures, or at other follow-up intervals. Both study groups exhibited clinically significant PTSD symptoms at all timepoints after ICU discharge. Follow-up phone interviews with patients revealed that while many were interested in getting follow-up for their symptoms, there were many barriers to accessing appropriate therapy and clinical attention. CONCLUSIONS:Results from psychological screening tools demonstrate no benefit of ICU diaries versus bedside education-alone in reducing PTSD symptoms related to the intensive care stay. However, our study finds an important gap in clinical practice - patients at high risk for PICS are infrequently connected to appropriate follow-up care. Perhaps ICU diaries would prove beneficial if utilized to support the work within a program providing wrap-around services and close psychiatric follow up for PICS patients. This study demonstrates the high prevalence of ICU-related PTSD in our cohort of survivors, the high barrier to accessing care for appropriate treatment of PICS, and the consequence of that barrier-prolonged psychological morbidity. TRIAL REGISTRATION:NCT04305353. GRANT IDENTIFICATION:GH-17-022 (Arnold P. Gold Foundation).
Healthcare trajectories before and after critical illness: population-based insight on diverse patients clusters.
Jouan Youenn,Grammatico-Guillon Leslie,Teixera Noémie,Hassen-Khodja Claire,Gaborit Christophe,Salmon-Gandonnière Charlotte,Guillon Antoine,Ehrmann Stephan
Annals of intensive care
BACKGROUND:The post intensive care syndrome (PICS) gathers various disabilities, associated with a substantial healthcare use. However, patients' comorbidities and active medical conditions prior to intensive care unit (ICU) admission may partly drive healthcare use after ICU discharge. To better understand retative contribution of critical illness and PICS-compared to pre-existing comorbidities-as potential determinant of post-critical illness healthcare use, we conducted a population-based evaluation of patients' healthcare use trajectories. RESULTS:Using discharge databases in a 2.5-million-people region in France, we retrieved, over 3 years, all adult patients admitted in ICU for septic shock or acute respiratory distress syndrome (ARDS), intubated at least 5 days and discharged alive from hospital: 882 patients were included. Median duration of mechanical ventilation was 11 days (interquartile ranges [IQR] 8;20), mean SAPS2 was 49, and median hospital length of stay was 42 days (IQR 29;64). Healthcare use (days spent in healthcare facilities) was analyzed 2 years before and 2 years after ICU admission. Prior to ICU admission, we observed, at the scale of the whole study population, a progressive increase in healthcare use. Healthcare trajectories were then explored at individual level, and patients were assembled according to their individual pre-ICU healthcare use trajectory by clusterization with the K-Means method. Interestingly, this revealed diverse trajectories, identifying patients with elevated and increasing healthcare use (n = 126), and two main groups with low (n = 476) or no (n = 251) pre-ICU healthcare use. In ICU, however, SAPS2, duration of mechanical ventilation and length of stay were not different across the groups. Analysis of post-ICU healthcare trajectories for each group revealed that patients with low or no pre-ICU healthcare (which represented 83% of the population) switched to a persistent and elevated healthcare use during the 2 years post-ICU. CONCLUSION:For 83% of ARDS/septic shock survivors, critical illness appears to have a pivotal role in healthcare trajectories, with a switch from a low and stable healthcare use prior to ICU to a sustained higher healthcare recourse 2 years after ICU discharge. This underpins the hypothesis of long-term critical illness and PICS-related quantifiable consequences in healthcare use, measurable at a population level.
Robotic technology provides objective and quantifiable metrics of neurocognitive functioning in survivors of critical illness:A feasibility study.
Wood Michael D,Maslove David M,Muscedere John,Scott Stephen H,Boyd J Gordon,
Journal of critical care
PURPOSE:To assess the feasibility of using an integrated multimodal data collection strategy to characterize the post-intensive care syndrome (PICS). MATERIALS AND METHODS:Adult patients admitted to the ICU requiring invasive mechanical ventilation for >24 h and/or requiring vasopressor support were eligible for enrollment. We assessed cognitive and sensorimotor function at 3- and 12-months after ICU discharge with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and with the KINARM robot. RESULTS:At 3- and 12-months after ICU discharge, 28/70 (40%) and 22/70 (31%) returned for follow-up testing, respectively. Prominent reasons for declining testing at 3- and 12-months included: not interested (40% and 38%) and health complications (31% and 31%). The majority of returning participants completed all tasks (96%-100%) and 100% of available data was recorded. On the RBANS, 54% (3 months) and 32% (12 months) of individuals were impaired in visuospatial/constructional skills. Similarly, the KINARM assessments demonstrated that 56% of individuals had visuospatial/executive dysfunction at 3 months, and 40% had impairment at 12 months. Individual scores indicated substantial variability. CONCLUSIONS:We demonstrated that it was feasible to quantify neurological dysfunction among participants that returned for follow-up testing. However, future investigations will need to implement multiple retention strategies. TRIAL REGISTRATION:This trial is registered on clinicaltrials.gov (Identifier: NCT02344043), retrospectively registered January 8, 2015.
Trajectories of depression in sepsis survivors: an observational cohort study.
Boede Monique,Gensichen Jochen S,Jackson James C,Eißler Fiene,Lehmann Thomas,Schulz Sven,Petersen Juliana J,Wolf Florian P,Dreischulte Tobias,Schmidt Konrad F R
Critical care (London, England)
BACKGROUND:Advances in critical care medicine have led to a growing number of critical illness survivors. A considerable part of them suffers from long-term sequelae, also known as post-intensive care syndrome. Among these, depressive symptoms are frequently observed. Depressive symptom trajectories and associated factors of critical illness survivors have rarely been investigated. Study objective was to explore and compare different trajectories of depressive symptoms in sepsis survivors over 1 year after discharge from ICU. METHODS:Data of a randomized controlled trial on long-term post-sepsis care were analyzed post hoc. Depressive symptoms were collected at 1, 6 and 12 months post-ICU discharge using the Major Depression Inventory (MDI), among others. Statistical analyses comprised descriptive analysis, univariate and multivariate, linear and logistic regression models and Growth Mixture Modeling. RESULTS:A total of 224 patients were included into this analysis. We identified three latent classes of depressive symptom trajectories: Over the course of 1 year, 152 patients recovered from mild symptoms, 27 patients showed severe persistent symptoms, and 45 patients recovered from severe symptoms. MDI sum scores significantly differed between the three classes of depressive symptom trajectories at 1 and 6 months after ICU discharge (p < 0.024 and p < 0.001, respectively). Compared with other classes, patients with the mild recovered trajectory showed lower levels of chronic pain (median sum score of 43.3 vs. 60.0/53.3 on the Graded Chronic Pain Scale, p < 0.010) and posttraumatic stress (4.6% with a sum score of ≥ 35 on the Posttraumatic Stress Scale 10 vs. 48.1%/33.3%, p < 0.003); and higher levels of health-related quality of life (HRQOL) using the Short Form-36 scale within 1 month after ICU discharge (p < 0.035). CONCLUSIONS:In the first year after discharge from ICU, sepsis survivors showed three different trajectories of depressive symptoms. Course and severity of depressive symptoms were associated with chronic pain, posttraumatic stress and reduced HRQOL at discharge from ICU. Regular screening of sepsis survivors on symptoms of depression, chronic pain and posttraumatic stress within 1 year after ICU may be considered. Trial registration ISRCTN, ISRCTN 61744782. Registered April 19, 2011-Retrospectively registered, http://www.isrctn.com/ISRCTN61744782 .
Cognitive Dysfunction After Analgesia and Sedation: Out of the Operating Room and Into the Pediatric Intensive Care Unit.
Frontiers in behavioral neuroscience
In the midst of concerns for potential neurodevelopmental effects after surgical anesthesia, there is a growing awareness that children who require sedation during critical illness are susceptible to neurologic dysfunctions collectively termed pediatric post-intensive care syndrome, or PICS-p. In contrast to healthy children undergoing elective surgery, critically ill children are subject to inordinate neurologic stress or injury and need to be considered separately. Despite recognition of PICS-p, inconsistency in techniques and timing of post-discharge assessments continues to be a significant barrier to understanding the specific role of sedation in later cognitive dysfunction. Nonetheless, available pediatric studies that account for analgesia and sedation consistently identify sedative and opioid analgesic exposures as risk factors for both in-hospital delirium and post-discharge neurologic sequelae. Clinical observations are supported by animal models showing neuroinflammation, increased neuronal death, dysmyelination, and altered synaptic plasticity and neurotransmission. Additionally, intensive care sedation also contributes to sleep disruption, an important and overlooked variable during acute illness and post-discharge recovery. Because analgesia and sedation are potentially modifiable, understanding the underlying mechanisms could transform sedation strategies to improve outcomes. To move the needle on this, prospective clinical studies would benefit from cohesion with regard to datasets and core outcome assessments, including sleep quality. Analyses should also account for the wide range of diagnoses, heterogeneity of this population, and the dynamic nature of neurodevelopment in age cohorts. Much of the related preclinical evidence has been studied in comparatively brief anesthetic exposures in healthy animals during infancy and is not generalizable to critically ill children. Thus, complementary animal models that more accurately "reverse translate" critical illness paradigms and the effect of analgesia and sedation on neuropathology and functional outcomes are needed. This review explores the interactive role of sedatives and the neurologic vulnerability of critically ill children as it pertains to survivorship and functional outcomes, which is the next frontier in pediatric intensive care.
Clinical Utility of a Structured Program to Reduce the Risk of Health-Related Quality of Life Impairment after Discharge from Intensive Care Unit: A Real-World Experience.
Venni Angelica,Ioia Francesca,Laviola Silvia,Frigieri Francesca,Pieri Alessandra,Marilli Simona,Balzi Daniela,Ballo Piercarlo,Gori Stefano,Guarducci Diletta
Critical care research and practice
BACKGROUND:Postdischarge deterioration in health-related quality of life (HRQoL) is a major clinical issue for patients after an intensive care unit (ICU) hospitalization. A significant proportion of these patients is known to develop a progressive worsening of mental and physical performance-the so-called post-intensive care syndrome (PICS). AIM:We aimed at exploring the effects of a structured program for the management of ICU patients, aimed at improving postdischarge HRQoL and reducing the risk of PICS. METHODS:A total of 159 patients hospitalized in our ICU with a length of stay >72 hours were enrolled in an institutional management protocol including specific recommendations: adequate sedation and analgesia protocols, to ensure a valid delirium prevention strategy, and to provide a planned midterm after discharge. The main endpoint was the occurrence of PICS at the 6-month follow-up visitation, defined as an abnormal physical or mental score in the SF-12 questionnaire in the presence of clinical evidence of new or worsening impairment in physical, cognitive, or mental health status. An additional questionnaire was administered, to assess the effects of ICU-related memories. RESULTS:Most patients positively rated their health at the 6-month follow-up and had no significant impairment in physical or mental health status. The mean normalized values of the physical and mental component of the SF-12 score were 46 ± 11 and 48 ± 14, suggesting a normal physical and mental health status in most patients. Twenty-nine patients (18.2%) showed evidence of PICS. Similar good results were found by the questionnaire of memories. In multivariable analysis, no variable was found to predict the risk of PICS in our population. CONCLUSION:In this real-world analysis that lacks a control group, patients who used a program aimed at minimizing the risk of HRQoL deterioration and PICS reported a good perception of their state of health with a relatively low prevalence of PICS.
Determinants of self-reported unacceptable outcome of intensive care treatment 1 year after discharge.
Kerckhoffs Monika C,Kosasi Felicia F L,Soliman Ivo W,van Delden Johannes J M,Cremer Olaf L,de Lange Dylan W,Slooter Arjen J C,Kesecioglu Jozef,van Dijk Diederik
Intensive care medicine
PURPOSE:Survivors of critical illness often suffer from reduced health-related quality of life (HRQoL) due to long-term physical, cognitive, and mental health problems, also known as post-intensive care syndrome (PICS). Some intensive care unit (ICU) survivors even consider their state of health unacceptable. The aim of this study was to investigate the determinants of self-reported unacceptable outcome of ICU treatment. METHODS:Patients who were admitted to the ICU for at least 48 h and survived the first year after discharge completed validated questionnaires on overall HRQoL and the components of PICS and stated whether they considered their current state of health an acceptable outcome of ICU treatment. The effects of overall HRQoL and components of PICS on unacceptable outcome were studied using multiple logistic regression analysis. RESULTS:Of 1453 patients, 67 (5%) reported their health state an unacceptable outcome of ICU treatment. These patients had a lower score on overall HRQoL (EQ-5D-index value of 0.57 vs. 0.81; p < 0.001), but we could not determine a cutoff value of the EQ-5D-index value that reliably identified unacceptable outcome. In the multivariate analysis, only the hospital anxiety and depression scale was significantly associated with an unacceptable outcome (OR 2.06, 99% CI 1.18-3.61). CONCLUSIONS:Although there is a strong association between low overall HRQoL and self-reported unacceptable outcome of ICU treatment, patients with low overall HRQoL may still consider their outcome acceptable. The mental component of PICS, but not the physical and cognitive component, is strongly associated with self-reported unacceptable outcome.
Enhanced Recovery after Intensive Care (ERIC): study protocol for a German stepped wedge cluster randomised controlled trial to evaluate the effectiveness of a critical care telehealth program on process quality and functional outcomes.
Adrion Christine,Weiss Bjoern,Paul Nicolas,Berger Elke,Busse Reinhard,Marschall Ursula,Caumanns Jörg,Rosseau Simone,Mansmann Ulrich,Spies Claudia,
INTRODUCTION:Survival after critical illness has noticeably improved over the last decades due to advances in critical care medicine. Besides, there is an increasing number of elderly patients with chronic diseases being treated in the intensive care unit (ICU). More than half of the survivors of critical illness suffer from medium-term or long-term cognitive, psychological and/or physical impairments after ICU discharge, which is recognised as post-intensive care syndrome (PICS). There are evidence-based and consensus-based quality indicators (QIs) in intensive care medicine, which have a positive influence on patients' long-term outcomes if adhered to. METHODS AND ANALYSIS:The protocol of a multicentre, pragmatic, stepped wedge cluster randomised controlled, quality improvement trial is presented. During 3 predefined steps, 12 academic hospitals in Berlin and Brandenburg, Germany, are randomly selected to move in a one-way crossover from the control to the intervention condition. After a multifactorial training programme on QIs and clinical outcomes for site personnel, ICUs will receive an adapted, interprofessional protocol for a complex telehealth intervention comprising of daily telemedical rounds at ICU. The targeted sample size is 1431 patients. The primary objective of this trial is to evaluate the effectiveness of the intervention on the adherence to eight QIs daily measured during the patient's ICU stay, compared with standard of care. Furthermore, the impact on long-term recovery such as PICS-related, patient-centred outcomes including health-related quality of life, mental health, clinical assessments of cognition and physical function, all-cause mortality and cost-effectiveness 3 and 6 months after ICU discharge will be evaluated. ETHICS AND DISSEMINATION:This protocol was approved by the ethics committee of the Charité-Universitätsmedizin, Berlin, Germany (EA1/006/18). The results will be published in a peer-reviewed scientific journal and presented at international conferences. Study findings will also be disseminated via the website (www.eric-projekt.net). TRIAL REGISTRATION NUMBER:ClinicalTrials.gov Registry (NCT03671447).
A protocol for tracking outcomes post intensive care.
Nursing in critical care
BACKGROUND:Critically ill patients are more likely to survive intensive care than ever before due to advances in treatment. However, a proportion subsequently experiences post-intensive care syndrome (PICS) incurring substantial personal, social, and economic costs. PICS is a debilitating set of physical, psychological, and cognitive sequelae but the size and characteristics of the affected population have been difficult to describe, impeding progress in intensive care rehabilitation. AIMS AND OBJECTIVES:The aim of this protocol is to describe recovery after admission to intensive care unit (ICU) and the predictors, correlates, and patient-reported outcomes for those experiencing PICS. The study will support the development of screening, diagnostic, and outcome measures to improve post-ICU recovery. DESIGN:A prospective, multi-site observational study in three ICUs in Brisbane, Australia. Following consent, data will be collected from clinical records and using validated self-report instruments from 300 patients, followed up at 6 weeks and 6 months post ICU discharge. METHODS:TOPIC is a prospective, multi-site observational study using self-report and clinical data on risk factors, including comorbidities, and outcomes. Data will be collected with consent from hospital records and participants 6 weeks and 6months post ICU discharge. RESULTS:The main outcome measures will be self-reported physical, cognitive, and psychological function 6 weeks and 6 months post-ICU discharge. RELEVANCE TO CLINICAL PRACTICE:This protocol provides a methodological framework to measure recovery and understand PICS. Data analysis will describe characteristics associated with recovery and PICS. The subsequent prediction and screening tools developed then aim to improve the effectiveness of post-ICU prevention and rehabilitation through more targeted screening and prediction and found a program of research developing a more tailored approach to PICS.
Long-term outcomes after critical illness: recent insights.
Rousseau Anne-Françoise,Prescott Hallie C,Brett Stephen J,Weiss Björn,Azoulay Elie,Creteur Jacques,Latronico Nicola,Hough Catherine L,Weber-Carstens Steffen,Vincent Jean-Louis,Preiser Jean-Charles
Critical care (London, England)
Intensive care survivors often experience post-intensive care sequelae, which are frequently gathered together under the term "post-intensive care syndrome" (PICS). The consequences of PICS on quality of life, health-related costs and hospital readmissions are real public health problems. In the present Viewpoint, we summarize current knowledge and gaps in our understanding of PICS and approaches to management.
Critical Care Recovery Center: a model of agile implementation in intensive care unit (ICU) survivors.
Wang Sophia,Hanneman Philip,Xu Chenjia,Gao Sujuan,Allen Duane,Golovyan Dmitry,Kheir You Na,Fowler Nicole,Austrom Mary,Khan Sikandar,Boustani Malaz,Khan Babar
BACKGROUND:As many as 70% of intensive care unit (ICU) survivors suffer from long-term physical, cognitive, and psychological impairments known as post-intensive care syndrome (PICS). We describe how the first ICU survivor clinic in the United States, the Critical Care Recovery Center (CCRC), was designed to address PICS using the principles of Agile Implementation (AI). METHODS:The CCRC was designed using an eight-step process known as the AI Science Playbook. Patients who required mechanical ventilation or were delirious ≥48 hours during their ICU stay were enrolled in the CCRC. One hundred twenty subjects who completed baseline HABC-M CG assessments and had demographics collected were included in the analysis to identify baseline characteristics that correlated with higher HABC-M CG scores. A subset of patients and caregivers also participated in focus group interviews to describe their perceptions of PICS. RESULTS:Quantitative analyses showed that the cognitive impairment was a major concern of caregivers. Focus group data also confirmed that caregivers of ICU survivors (n = 8) were more likely to perceive cognitive and mental health symptoms than ICU survivors (n = 10). Caregivers also described a need for ongoing psychoeducation about PICS, particularly cognitive and mental health symptoms, and for ongoing support from other caregivers with similar experiences. CONCLUSIONS:Our study demonstrated how the AI Science Playbook was used to build the first ICU survivor clinic in the United States. Caregivers of ICU survivors continue to struggle with PICS, particularly cognitive impairment, months to years after discharge. Future studies will need to examine whether the CCRC model of care can be adapted to other complex patient populations seen by health-care professionals.
Parental Posttraumatic Stress Symptoms in the Context of Pediatric Post Intensive Care Syndrome: Impact on the Family and Opportunities for Intervention.
Clinical practice in pediatric psychology
OBJECTIVE:Pediatric intensive care unit (PICU) survivors and their families experience ongoing impacts on physical, cognitive, and psychosocial functioning, described as Post-Intensive Care Syndrome (PICS). The objective of this study was to determine whether the posttraumatic stress symptoms (PTSS) of parents predict the impact of critical illness on families following PICU admission beyond other factors (e.g., sex, race/ethnicity, age, insurance status, illness severity, family involvement or death). METHOD:We conducted a retrospective analysis of data from 88 children aged 1 month to 18 years who were hospitalized with critical illness and acquired brain injury in the PICU and their families. Patients and their families participated in a 1-3 month post-discharge follow-up assessment, during which data on demographics, medical diagnoses, parent self-report of PTSS, and family impact of critical illness (via the Pediatric Quality of Life Family Impact Module) were collected. We used a hierarchical linear regression to determine whether parent PTSS predicted family impact above and beyond demographic and injury/illness factors. RESULTS:One-third of parents reported elevated PTSS. Among those with complete available data = 56), PTSS were the only significant predictor of family impact (β = -.52, = -3.58, = .001), with the overall model accounting for 41% of variance. CONCLUSION:In addition to the direct effects on parents of children who survive the PICU, PTSS may negatively impact families and interfere with rehabilitative progress. We provide a rationale and conceptual model for integrating interventions designed to address parent PTSS into post-PICU care.
Pediatric postintensive care syndrome: high burden and a gap in evaluation tools for limited-resource settings.
Chaiyakulsil Chanapai,Opasatian Rapee,Tippayawong Paweethida
Clinical and experimental pediatrics
This article aimed to summarize the impact and burden of pediatric postintensive care syndrome (PICS-p) in the physical, mental, cognitive, and social health domains after a review of the current pediatric literature in MEDLINE and PubMed. We also aimed to elucidate the limitations of the current evaluation tools used in limited-resource settings. PICS-p can impact a child's life for decades. Most validated tools are time-consuming, require qualifications, and expertise, are often limited to older children, and can evaluate only one domain. A novel, simple, and comprehensive surveillance tool can aid healthcare providers in the early detection and intervention of PICS-p. Further studies should validate and refine the parameters that will enhance the outcomes of pediatric intensive care unit survivors.
Stress Management Intervention to Prevent Post-Intensive Care Syndrome-Family in Patients' Spouses.
Cairns Paula L,Buck Harleah G,Kip Kevin E,Rodriguez Carmen S,Liang Zhan,Munro Cindy L
American journal of critical care : an official publication, American Association of Critical-Care Nurses
BACKGROUND:Post-intensive care syndrome-family (PICS-F) refers to acute and chronic psychological effects of critical care on family members of patients in intensive care units (ICUs). Evidence suggests that increased distress during the ICU stay increases risk of PICS-F. Sensation Awareness Focused Training (SĀF-T) is a new, promising stress management intervention, but the feasibility of such training during the ICU stay for family caregivers who are acting as the surrogate decision-maker for patients who are undergoing mechanical ventilation is unknown. OBJECTIVES:To assess feasibility and acceptability of SĀF-T to inform a future larger randomized controlled trial. METHODS:This randomized controlled trial of SĀF-T (n = 5) versus a control (n = 5) group was conducted at a level 1 trauma center. Participants assigned to SĀF-T completed 1 session daily for 3 days. Measures included enrollment rate, data completion rate, acceptability of SĀF-T, and symptoms of PICS-F. Scales used included Perceived Stress, Hospital Anxiety and Depression, Impact of Event, and National Institutes of Health Toolbox Emotion Battery. RESULTS:Mean age was 58 (SD, 12) years; 70% of participants were female. Predetermined feasibility criteria were met in enrollment rate (67%), outcome measures completion rate (> 90%), and SĀF-T acceptability (100% of doses completed during the ICU stay) without adverse events. Stress scores after SĀF-T were significantly lower than scores before SĀF-T ( = -3.5, = .01). CONCLUSIONS:SĀF-T intervention during the ICU stay is feasible, acceptable, and may improve family caregivers' post-ICU outcomes. Larger clinical trial to assess the effectiveness of SĀF-T in preventing PICS-F seem warranted.
Aging and Post-Intensive Care Syndrome: A Critical Need for Geriatric Psychiatry.
Wang Sophia,Allen Duane,Kheir You Na,Campbell Noll,Khan Babar
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry
Because of the aging of the intensive care unit (ICU) population and an improvement in survival rates after ICU hospitalization, an increasing number of older adults are suffering from long-term impairments because of critical illness, known as post-intensive care syndrome (PICS). This article focuses on PICS-related cognitive, psychological, and physical impairments and the impact of ICU hospitalization on families and caregivers. The authors also describe innovative models of care for PICS and what roles geriatric psychiatrists could play in the future of this rapidly growing population.
Characteristics of postintensive care syndrome in survivors of pediatric critical illness: A systematic review.
Herrup Elizabeth A,Wieczorek Beth,Kudchadkar Sapna R
World journal of critical care medicine
AIM:To synthesize the available evidence focusing on morbidities in pediatric survivors of critical illness that fall within the defined construct of postintensive care syndrome (PICS) in adults, including physical, neurocognitive and psychological morbidities. METHODS:A comprehensive search was conducted in MEDLINE, EMBASE, the Cochrane Library, PsycINFO, and CINAHL using controlled vocabulary and key word terms to identify studies reporting characteristics of PICS in pediatric intensive care unit (PICU) patients. Two reviewers independently screened all titles and abstracts and performed data extraction. From the 3176 articles identified in the search, 252 abstracts were identified for full text review and nineteen were identified for inclusion in the review. All studies reporting characteristics of PICS in PICU patients were included in the final synthesis. RESULTS:Nineteen studies meeting inclusion criteria published between 1995 and 2016 were identified and categorized into studies reporting morbidities in each of three categories-physical, neurocognitive and psychological. The majority of included articles reported prospective cohort studies, and there was significant variability in the outcome measures utilized. A synthesis of the studies indicate that morbidities encompassing PICS are well-described in children who have survived critical illness, often resolving over time. Risk factors for development of these morbidities include younger age, lower socioeconomic status, increased number of invasive procedures or interventions, type of illness, and increased benzodiazepine and narcotic administration. CONCLUSION:PICS-related morbidities impact a significant proportion of children discharged from PICUs. In order to further define PICS in children, more research is needed using standardized tools to better understand the scope and natural history of morbidities after hospital discharge. Improving our understanding of physical, neurocognitive, and psychological morbidities after critical illness in the pediatric population is imperative for designing interventions to improve long-term outcomes in PICU patients.
Post-intensive care syndrome after a critical COVID-19: cohort study from a Belgian follow-up clinic.
Rousseau Anne-Françoise,Minguet Pauline,Colson Camille,Kellens Isabelle,Chaabane Sourour,Delanaye Pierre,Cavalier Etienne,Chase J Geoffrey,Lambermont Bernard,Misset Benoit
Annals of intensive care
PURPOSE:Many patients with coronavirus disease 2019 (COVID-19) required critical care. Mid-term outcomes of the survivors need to be assessed. The objective of this single-center cohort study was to describe their physical, cognitive, psychological, and biological outcomes at 3 months following intensive care unit (ICU)-discharge (M3). PATIENTS AND METHODS:All COVID-19 adults who survived an ICU stay ≥ 7 days and attended the M3 consultation at our multidisciplinary follow-up clinic were involved. They benefited from a standardized assessment, addressing health-related quality of life (EQ-5D-3L), sleep disorders (PSQI), and the three principal components of post-intensive care syndrome (PICS): physical status (Barthel index, handgrip and quadriceps strength), mental health disorders (HADS and IES-R), and cognitive impairment (MoCA). Biological parameters referred to C-reactive protein and creatinine. RESULTS:Among the 92 patients admitted to our ICU for COVID-19, 42 survived a prolonged ICU stay and 32 (80%) attended the M3 follow-up visit. Their median age was 62 [49-68] years, 72% were male, and nearly half received inpatient rehabilitation following ICU discharge. At M3, 87.5% (28/32) had not regained their baseline level of daily activities. Only 6.2% (2/32) fully recovered, and had normal scores for the three MoCA, IES-R and Barthel scores. The main observed disorders were PSQI > 5 (75%, 24/32), MoCA < 26 (44%, 14/32), Barthel < 100 (31%, 10/32) and IES-R ≥ 33 (28%, 9/32). Combined disorders were observed in 13/32 (40.6%) of the patients. The EQ-5D-3L visual scale was rated at 71 [61-80]. A quarter of patients (8/32) demonstrated a persistent inflammation based on CRP blood level (9.3 [6.8-17.7] mg/L). CONCLUSION:The burden of severe COVID-19 and prolonged ICU stay was considerable in the present cohort after 3 months, affecting both functional status and biological parameters. These data are an argument on the need for closed follow-up for critically ill COVID-19 survivors.
Post-intensive Care Syndrome.
Ahmad Muhammad Hanif,Teo Shyh Poh
Annals of geriatric medicine and research
The increasing survival rate after discharge from the intensive care unit (ICU) has revealed long-term impairments in the cognitive, psychiatric, and physical domains among survivors. However, clinicians often fail to recognize this post-ICU syndrome (PICS) and its debilitating effects on family members (PICS-F). This study describes two cases of PICS to illustrate the different impairments that may occur in ICU survivors. The PICS risk factors for each domain and the interactions among risk factors are also described. In terms of diagnostic evaluation, limited evidence-based or validated tools are available to assist with screening for PICS. Clinicians should be aware to monitor for its symptoms on the basis of cognitive, psychiatric, and physical domains. The Montreal Cognitive Assessment is recommended to screen for cognition, as it has a high sensitivity and can evaluate executive function. Mood disorders should also be screened. For mobile patients, a 6-minute walk test should be performed. PICS can be prevented by applying the ABCDEF bundle ABCDEF bundle in ICU described in this paper. Finally, the family members of patients in the ICU should be involved in patient care and a tactful communication approach is required to reduce the risk of PICS-F.
[Research progress on evaluation tools for post-intensive care syndrome].
Zhang Xuezhang,Zhang Liwen,Liu Pengfei,Li Wei
Zhonghua wei zhong bing ji jiu yi xue
OBJECTIVE:With advances in intensive care, more patients are surviving from critical illness, and post-intensive care syndrome (PICS) began to get people's attention. Early detection and intervention of PICS can improve the quality of life of intensive care unit (ICU) survivors and reduce the rate of re-hospitalization. However, effective, reliable, and easy-to-use assessment tools are the basis for early detection and evaluation of intervention outcomes. Thus, we introduce the evaluation tools for PICS from the perspective of universality or specificity, aim to provide reference for doctors or nurses to choose suitable assessment tools for PICS, and to provide reference for the development of localized assessment tools for PICS in China, so as to promote the related research of PICS.
Smartphone Delivery of Cognitive Behavioral Therapy for Postintensive Care Syndrome-Family: Protocol for a Pilot Study.
Petrinec Amy B,Hughes Joel W,Zullo Melissa D,Wilk Cindy,George Richard L
JMIR research protocols
BACKGROUND:Family members of critically ill patients experience symptoms of postintensive care syndrome-family (PICS-F), including anxiety, depression, and posttraumatic stress disorder. Postintensive care syndrome-family reduces the quality of life of the families of critically ill patients and may impede the recovery of such patients. Cognitive behavioral therapy has become a first-line nonpharmacological treatment of many psychological symptoms and disorders, including anxiety, depression, and posttraumatic stress. With regard to managing mild-to-moderate symptoms, the delivery of cognitive behavioral therapy via mobile technology without input from a clinician has been found to be feasible and well accepted, and its efficacy rivals that of face-to-face therapy. OBJECTIVE:The purpose of our pilot study is to examine the efficacy of using a smartphone mobile health (mHealth) app to deliver cognitive behavioral therapy and diminish the severity and prevalence of PICS-F symptoms in family members of critically ill patients. METHODS:For our pilot study, 60 family members of critically ill patients will be recruited. A repeated-measures longitudinal study design that involves the randomization of participants to 2 groups (the control and intervention groups) will be used. The intervention group will receive cognitive behavioral therapy, which will be delivered via a smartphone mHealth app. Bandura's social cognitive theory and an emphasis on mental health self-efficacy form the theoretical framework of the study. RESULTS:Recruitment for the study began in August 2020. Data collection and analysis are expected to be completed by March 2022. CONCLUSIONS:The proposed study represents a novel approach to the treatment of PICS-F symptoms and is an extension of previous work conducted by the research team. The study will be used to plan a fully powered randomized controlled trial. TRIAL REGISTRATION:ClinicalTrials.gov NCT04316767; https://clinicaltrials.gov/ct2/show/NCT04316767. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID):DERR1-10.2196/30813.
Sepsis Induces Physical and Mental Impairments in a Mouse Model of Post-Intensive Care Syndrome.
Fujinami Yoshihisa,Inoue Shigeaki,Ono Yuko,Miyazaki Yusuke,Fujioka Kazumichi,Yamashita Kimihiro,Kotani Joji
Journal of clinical medicine
Post-intensive care syndrome (PICS) is a physical, cognitive, and mental impairment observed in intensive care unit (ICU) survivors. Although this is an emerging problem in the ICU, how sepsis induces the characteristic symptoms of PICS remains unclear. To develop a model of PICS, we induced sepsis in male C57/B6 mice via sublethal cecum slurry injection and subsequently treated them using ICU-like interventions. At 1-2 weeks post-sepsis induction, we simultaneously evaluated the abilities of the surviving mice using the following behavioral tests: (1) a grip strength test (GST) and a treadmill test for physical assessment, (2) a novel object recognition test (NORT) for cognitive assessment, and (3) an open field test (OFT) and a marble burying test (MBT) for mental assessment. The surviving mice showed a range of deficits, including muscle weakness with significantly decreased grip strength in the GST; decreased total mileage during the treadmill test; anxiety and decreased activity, with significantly decreased time in the central area, and increased duration of immobility in the OFT; and an increased number of buried marbles in the MBT. Given these physical and mental impairments in the surviving mice, our model has the potential to elucidate mechanistic insights and to discover therapeutic targets and new interventions for PICS.
Long-Term Outcomes and the Post-Intensive Care Syndrome in Critically Ill Children: A North American Perspective.
Woodruff Alan G,Choong Karen
Children (Basel, Switzerland)
Advances in medical and surgical care for children in the pediatric intensive care unit (PICU) have led to vast reductions in mortality, but survivors often leave with newly acquired or worsened morbidity. Emerging evidence reveals that survivors of pediatric critical illness may experience a constellation of physical, emotional, cognitive, and social impairments, collectively known as the "post-intensive care syndrome in pediatrics" (PICs-P). The spectrum of PICs-P manifestations within each domain are heterogeneous. This is attributed to the wide age and developmental diversity of children admitted to PICUs and the high prevalence of chronic complex conditions. PICs-P recovery follows variable trajectories based on numerous patient, family, and environmental factors. Those who improve tend to do so within less than a year of discharge. A small proportion, however, may actually worsen over time. There are many gaps in our current understanding of PICs-P. A unified approach to screening, preventing, and treating PICs-P-related morbidity has been hindered by disparate research methodology. Initiatives are underway to harmonize clinical and research priorities, validate new and existing epidemiologic and patient-specific tools for the prediction or monitoring of outcomes, and define research priorities for investigators interested in long-term outcomes.
A Call for the World Health Organization to Create International Classification of Disease Diagnostic Codes for Post-Intensive Care Syndrome in the Age of COVID-19.
World medical & health policy
Post-intensive care syndrome (PICS), a condition found in survivors of critical illness, is characterized by persistent physical, cognitive, and psychological sequelae that impact the quality of life after discharge from an intensive care unit (ICU). At present, there are no International Classification of Disease (ICD) billing codes for this condition. Without financial alignment, clinicians cannot diagnose PICS, hindering tracking of its prevalence and impeding policy development for this condition. Clinicians should be screening for PICS in all survivors of critical illness, particularly those with acute respiratory distress syndrome (ARDS). Results from single-center studies suggest over 75 percent of ARDS survivors develop PICS. With nearly 5 percent of patients with COVID-19 requiring ICU admission for ARDS, it is important for clinicians to be able to diagnose PICS in survivors, and researchers to be able to track it. Member states should impress upon the World Health Organization to create ICD-10 codes for PICS.
Frequency and risk factors of post-intensive care syndrome components in a multicenter randomized controlled trial of German sepsis survivors.
Kosilek R P,Schmidt K,Baumeister S E,Gensichen J,
Journal of critical care
BACKGROUND:Post-intensive care syndrome (PICS) is a combination of cognitive, psychiatric and physical impairments in survivors of critical illness and intensive care. There is little data on long-term co-occurrence of associated impairments. METHODS:Analysis of data from 289 sepsis survivors from a German multicenter RCT. Impairments associated with PICS (depression, PTSD, cognitive impairment, chronic pain, neuropathic symptoms, dysphagia) during 24 months follow-up are used to explore the frequency and risk factors of PICS components in three classification models. RESULTS:The majority of participants showed impairments in 2-3 of 6 domains during follow-up. The overall frequency of PICS according to the classification models ranged from 32.9% to 98.6%. In regression analyses, there were no significant effects in selected ICU-related exposures or covariates for PICS classification models. Regarding individual components, only higher age and longer duration of ICU treatment and mechanical ventilation showed significant positive associations with the occurrence of cognitive impairment during follow-up, as did male gender and higher age for dysphagia. CONCLUSIONS:Almost all study participants showed impairments associated with PICS in at least one domain. The proposed classification models for PICS appear to be too broad to identify specific risk factors beyond its individual components.
The effects of intensive care unit-initiated transitional care interventions on elements of post-intensive care syndrome: A systematic review and meta-analysis.
Australian critical care : official journal of the Confederation of Australian Critical Care Nurses
OBJECTIVE:The aim of the study was to assess the effectiveness of intensive care unit (ICU)-initiated transitional care interventions for patients and families on elements of post-intensive care syndrome (PICS) and/or PICS-family (PICS--F). REVIEW METHOD USED:This is a systematic review and meta-analysis SOURCES: The authors searched in biomedical bibliographic databases including PubMed, Embase (OVID), CINAHL Plus (EBSCO), Web of Science, and the Cochrane Library and included studies written in English conducted up to October 8, 2020. REVIEW METHODS:We included (non)randomised controlled trials focussing on ICU-initiated transitional care interventions for patients and families. Two authors conducted selection, quality assessment, and data extraction and synthesis independently. Outcomes were described using the three elements of PICS, which were categorised into (i) physical impairments (pulmonary, neuromuscular, and physical function), (ii) cognitive impairments (executive function, memory, attention, visuo-spatial and mental processing speed), and (iii) psychological health (anxiety, depression, acute stress disorder, post-traumatic stress disorder, and depression). RESULTS:From the initially identified 5052 articles, five studies were included (i.e., two randomised controlled trials and three nonrandomised controlled trials) with varied transitional care interventions. Quality among the studies differs from moderate to high risk of bias. Evidence from the studies shows no significant differences in favour of transitional care interventions on physical or psychological aspects of PICS-(F). One study with a nurse-led structured follow-up program showed a significant difference in physical function at 3 months. CONCLUSIONS:Our review revealed that there is a paucity of research about the effectiveness of transitional care interventions for ICU patients with PICS. All, except one of the identified studies, failed to show a significant effect on the elements of PICS. However, these results should be interpreted with caution owing to variety and scarcity of data. PROSPERO REGISTRATION:CRD42020136589 (available via https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020136589).
Home and Community-Based Physical Therapist Management of Adults With Post-Intensive Care Syndrome.
Smith James M,Lee Alan C,Zeleznik Hallie,Coffey Scott Jacqueline P,Fatima Arooj,Needham Dale M,Ohtake Patricia J
More than 4 million adults survive a stay in the intensive care unit each year, with many experiencing new or worsening physical disability, mental health problems, and/or cognitive impairments, known as post-intensive care syndrome (PICS). Given the prevalence and magnitude of physical impairments after critical illness, many survivors, including those recovering from COVID-19, could benefit from physical therapist services after hospital discharge. However, due to the relatively recent recognition and characterization of PICS, there may be limited awareness and understanding of PICS among physical therapists practicing in home health care and community-based settings. This lack of awareness may lead to inappropriate and/or inadequate rehabilitation service provision. While this perspective article provides information relevant to all physical therapists, it is aimed toward those providing rehabilitation services outside of the acute and postacute inpatient settings. This article reports the prevalence and clinical presentation of PICS and provides recommendations for physical examination and outcomes measures, plan of care, and intervention strategies. The importance of providing patient and family education, coordinating community resources including referring to other health care team members, and community-based rehabilitation service options is emphasized. Finally, this perspective article discusses current challenges for optimizing outcomes for people with PICS and suggests future directions for research and practice.
Prevalence of post-intensive care syndrome among Japanese intensive care unit patients: a prospective, multicenter, observational J-PICS study.
Kawakami Daisuke,Fujitani Shigeki,Morimoto Takeshi,Dote Hisashi,Takita Mumon,Takaba Akihiro,Hino Masaaki,Nakamura Michitaka,Irie Hiromasa,Adachi Tomohiro,Shibata Mami,Kataoka Jun,Korenaga Akira,Yamashita Tomoya,Okazaki Tomoya,Okumura Masatoshi,Tsunemitsu Takefumi
Critical care (London, England)
BACKGROUND:Many studies have compared quality of life of post-intensive care syndrome (PICS) patients with age-matched population-based controls. Many studies on PICS used the 36-item Short Form (SF-36) health survey questionnaire version 2, but lack the data for SF-36 values before and after intensive care unit (ICU) admission. Thus, clinically important changes in the parameters of SF-36 are unknown. Therefore, we determined the frequency of co-occurrence of PICS impairments at 6 months after ICU admission. We also evaluated the changes in SF-36 subscales and interpreted the patients' subjective significance of impairment. METHODS:A prospective, multicenter, observational cohort study was conducted in 16 ICUs across 14 hospitals in Japan. Adult ICU patients expected to receive mechanical ventilation for > 48 h were enrolled, and their 6-month outcome was assessed using the questionnaires. PICS definition was based on the physical status, indicated by the change in SF-36 physical component score (PCS) ≥ 10 points; mental status, indicated by the change in SF-36 mental component score (MCS) ≥ 10 points; and cognitive function, indicated by the worsening of Short-Memory Questionnaire (SMQ) score and SMQ score at 6 months < 40. Multivariate logistic regression model was used to identify the factors associated with PICS occurrence. The patients' subjective significance of physical and mental symptoms was assessed using the 7-scale Global Assessment Rating to evaluate minimal clinically important difference (MCID). RESULTS:Among 192 patients, 48 (25%) died at 6 months. Among the survivors at 6 months, 96 patients responded to the questionnaire; ≥ 1 PICS impairment occurred in 61 (63.5%) patients, and ≥ 2 occurred in 17 (17.8%) patients. Physical, mental, and cognitive impairments occurred in 32.3%, 14.6% and 37.5% patients, respectively. Population with only mandatory education was associated with PICS occurrence (odds ratio: 4.0, 95% CI 1.1-18.8, P = 0.029). The MCID of PCS and MCS scores was 6.5 and 8.0, respectively. CONCLUSIONS:Among the survivors who received mechanical ventilation, 64% had PICS at 6 months; co-occurrence of PICS impairments occurred in 20%. PICS was associated with population with only mandatory education. Future studies elucidating the MCID of SF-36 scores among ICU patients and standardizing the PICS definition are required. Trial registration UMIN000034072.
Post Intensive Care Syndrome (PICS): an overview of the definition, etiology, risk factors, and possible counseling and treatment strategies.
Ramnarain Dharmanand,Aupers Emily,den Oudsten Brenda,Oldenbeuving Annemarie,de Vries Jolanda,Pouwels Sjaak
Expert review of neurotherapeutics
INTRODUCTION:Post-intensive care syndrome (PICS) has only recently been recognized as a new clinical entity in patients surviving their intensive care unit (ICU) stay due to critical illness. With increasing survival rates of ICU patients worldwide, there is a rising interest regarding post-ICU recovery. AREAS COVERED:First, based on the current literature a definition is provided of PICS, including the domains of impairments that comprise PICS along with the etiology and risk factors. Second, preventive measures and possible treatment strategies integrated in the follow-up care are described. Third, the authors will discuss the current SARS-Cov-2 pandemic and the increased risk of PICS in these post-ICU patients and their families. EXPERT OPINION:PICS is a relatively new entity, which not only encompasses various physical, cognitive, and psychological impairments but also impacts global health due to long-lasting detrimental socioeconomic burdens. Importantly, PICS also relates to caregivers of post-ICU patients. Strategies to reduce this burden will not only be needed within the ICU setting but will also have to take place in an interdisciplinary, multifaceted approach in primary care settings. Additionally, the SARS-Cov-2 pandemic has a high burden on post-ICU patients and their relatives.
Peer Support for Post Intensive Care Syndrome Self-Management (PS-PICS): Study protocol for peer mentor training.
Danesh Valerie,Hecht Jacki,Hao Richard,Boehm Leanne,Jimenez Edgar J,Arroliga Alejandro C,Sanghi Sandhya,Stevens Alan
Journal of advanced nursing
AIMS:The primary aim of the Peer Support for Post Intensive Care Syndrome Self-Management (PS-PICS) peer mentor training trial is to determine the feasibility for peer mentor training to connect new ICU survivors with survivors who have made successful recoveries. Secondary aims are to also examine peer mentor eligibility, recruitment and retention rates and assess changes in participant knowledge of Post Intensive Care Syndrome (PICS), reported symptoms and health-related quality of life. DESIGN:Prospective clinical feasibility trial. METHODS:This study received funding from the National Institutes of Health funded P30 Center for Excellence (2014-2020). Up to 20 adult patients who have had an ICU stay of 3 days or longer more than 3 months ago will be enrolled into the study. Participants will undergo a 6-week peer mentor training program to learn how to promote healthy self-management behaviours, social connections, and well-being using motivational interviewing (MI). Participants will complete surveys about their recovery at 3 points during the study: prior to training, 6 weeks post-training and 3 months post-training. Survey questions will be used to assess trends in participant social isolation, depression, functional status, and self-management behaviours. DISCUSSION:Enrollment closes by December 2020. As a feasibility trial, power sufficient for hypothesis testing will not be available. However, study operations and intervention fidelity contribute to future research knowledge and participant characteristics and longitudinal outcomes will yield data on intervention feasibility. This study is the first use of embedding peer-led motivational interviewing training into a peer support intervention for ICU survivors. IMPACT:Current self-management interventions are limited for ICU survivors and do not sufficiently address barriers to promoting self-management behaviours or improving their health status, well-being and cost of health. This study will provide data to develop and implement interventions for the self-management of PICS-related symptoms and sequelae.
Long term follow-up of quality of life and functional ability in patients with ICU acquired Weakness - A post hoc analysis.
Sidiras Georgios,Patsaki Irini,Karatzanos Eleftherios,Dakoutrou Maria,Kouvarakos Alexandros,Mitsiou Georgios,Routsi Christina,Stranjalis Georgios,Nanas Serafim,Gerovasili Vasiliki
Journal of critical care
PURPOSE:ICU acquired Weakness (ICUaW) is a common complication of critical illness. The aim of our study was the assessment of quality of life (QoL) and functional ability of patients with ICUaW, 6 months post hospital discharge. MATERIAL AND METHODS:Eight hundred seventy eight consecutive patients who had been discharged from the ICU were evaluated and 128 of them, 36 with ICUaW, were eligible for the study. Muscle strength was evaluated with MRC and Hand grip dynamometry. The Functional Independence Measure (FIM) was used to evaluate the functional ability while QoL was assessed with the Nottingham Health Profile and with the SF-36 questionnaire. RESULTS:Patients with ICUaW continued to have low MRC at hospital discharge, [53(49-56) vs. 59(58-60), p < 0.05]. Patients who developed ICUaW had lower Hand grip dynamometry at ICU, hospital discharge and 6 months after (p < 0.05). Patients with ICUaW have significantly lower FIM score at hospital discharge, 3 and 6 months post hospital discharge (p < 0.05) and persistently lower QoL at 3 and 6 months post hospital discharge(p < 0.05). CONCLUSIONS:ICUaW is associated with persistent deficiencies in functional ability and Qol leading to a prolonged period of recovery. Further research is needed in the field of prevention and targeted rehabilitation of functionality in this patient group.
Six-Minute Walk Distance After Critical Illness: A Systematic Review and Meta-Analysis.
Parry Selina M,Nalamalapu Swaroopa R,Nunna Krishidhar,Rabiee Anahita,Friedman Lisa Aronson,Colantuoni Elizabeth,Needham Dale M,Dinglas Victor D
Journal of intensive care medicine
BACKGROUND AND OBJECTIVES:Impaired physical functioning is common and long lasting after an intensive care unit (ICU) admission. The 6-minute walk test (6MWT) is a validated and widely used test of functional capacity. This systematic review synthesizes existing data in order to: (1) evaluate 6-minute walk distance (6MWD) in meters over longitudinal follow-up after critical illness, (2) compare 6MWD between acute respiratory distress syndrome (ARDS) versus non-ARDS survivors, and (3) evaluate patient- and ICU-related factors associated with 6MWD. DATA SOURCES:Five databases (PubMed, EMBASE, Cumulative Index of Nursing and Allied Health Literature, PsychINFO, and Cochrane Controlled Trials Registry) were searched to identify studies reporting 6MWT after hospital discharge in survivors from general (ie, nonspeciality) ICUs. The last search was run on February 14, 2018. Databases were accessed via Johns Hopkins University Library. DATA EXTRACTION AND SYNTHESIS:Pooled mean 6MWD were reported, with separate linear random effects models used to evaluate associations of 6MWD with ARDS status, and patient- and ICU-related variables. Twenty-six eligible articles on 16 unique participant groups were included. The pooled mean (95% confidence interval [CI]) 6MWD results at 3- and 12-months post discharge were 361 (321-401) and 436 (391-481) meters, respectively. There was a significant increase in 6MWD at 12 months compared to 3 months ( = .017). In ARDS versus non-ARDS survivors, the mean (95% CI) 6MWD difference over 3-, 6-, and 12-month follow-up was 73 [13-133] meters lower. Female sex and preexisting comorbidity also were significantly associated with lower 6MWD, with ICU-related variables having no consistent associations. CONCLUSIONS:Compared to initial assessment at 3 months, significant improvement in 6MWD was reported at 12 months. Female sex, preexisting comorbidity, and ARDS (vs non-ARDS) were associated with lower 6MWT results. Such factors warrant consideration in the design of clinical research studies and in the interpretation of patient status using the 6MWT.
Effects of the ABCDE bundle on the prevention of post-intensive care syndrome: A retrospective study.
Lee YoonMi,Kim Kyunghee,Lim Changwon,Kim Ji-Su
Journal of advanced nursing
AIM:To identify the effects of each domain of the early and modified ABCDE bundle on post-intensive care syndrome (PICS). DESIGN:This is a retrospective study. METHODS:We analysed the data from electronic medical records of 91 intensive care patients who received therapeutic interventions in stages, based on the early ABCDE bundle (admitted to the intensive care unit [ICU] from June - August 2013) and 94 patients who received interventions using a modified ABCDE bundle developed through continuous quality improvement activities (admitted to the ICU from June to August 2014). RESULTS:In the ABC domain, the percentage of patients showing sedation levels of alertness and calmness increased significantly from 58.2% using the early ABCDE bundle to 72.4% using the modified ABCDE bundle. Coma prevalence decreased significantly from 45.1% using the early ABCDE bundle to 28.7% using the modified ABCDE bundle. In the E domain, the percentage of patients receiving early mobility interventions increased significantly from 11% using the early ABCDE bundle to 54.3% using the modified ABCDE bundle. CONCLUSION:The ABCDE bundle in the ICU helped prevent PICS by reducing deep sedation and immobilization among intensive care patients. To effectively use the ABCDE bundle, it is necessary for institutions to develop suitable protocols for each constituent element and to test their effectiveness. IMPACT:The ABCDE bundle was a suitable tool to support evidence-based practice in intensive care patients, including oversedation and immobilization, which is related to the prevention of PICS. Individual institutions will need to actively use the ABCDE bundle in the ICU, by developing protocols and testing their effectiveness.
Activities of daily living status and psychiatric symptoms after discharge from an intensive care unit: a single-center 12-month longitudinal prospective study.
Acute medicine & surgery
AIM:In post-intensive care syndrome (PICS), long-term survivors of critical illness present various physical and mental symptoms that can persist for years after discharge. Post-intensive care syndrome in Japan has not been well described, so this study aims to elucidate its epidemiology. METHODS:We undertook a single-center prospective longitudinal cohort study in a mixed intensive care unit (ICU) in a Japanese tertiary hospital. Adult patients emergently admitted to the ICU were eligible for inclusion in the study. To assess activity of daily living (ADL) status and psychiatric symptoms, we posted a questionnaire at 3 and 12 months after discharge from the ICU. We evaluated ADL status, anxiety, depression, and post-traumatic stress disorder symptoms using the Barthel index, Hospital Anxiety and Depression Scale, and Impact of Event Scale - Revised, respectively. RESULTS:Enrolled in this study were 204 patients. We received responses from 117/147 (80%) and 74/98 (76%) patients at 3 and 12 months, respectively. At 3 months, the prevalence of ADL disability, anxiety, depression, and post-traumatic stress disorder symptoms was 32%, 42%, 48%, and 20%, respectively. At 12 months, the prevalence was 22%, 33%, 39%, and 21%, respectively. The prevalence of any symptoms was 66% at 3 months and 55% at 12 months. Barthel index score at 12 months was improved significantly from that at 3 months. Hospital Anxiety and Depression Scale and Impact of Event Scale - Revised scores at 12 months showed no improvement. CONCLUSIONS:At 3 and 12 months after ICU discharge, over half of our Japanese patients suffered ADL disability and/or psychiatric symptoms. The ADL disability improved at 1 year, but psychiatric symptoms did not.
Feasibility of a home-based interdisciplinary rehabilitation program for patients with Post-Intensive Care Syndrome: the REACH study.
Major Mel E,Dettling-Ihnenfeldt Daniela,Ramaekers Stephan P J,Engelbert Raoul H H,van der Schaaf Marike
Critical care (London, England)
BACKGROUND:Survivors of critical illness experience long-term functional challenges, which are complex, heterogeneous, and multifactorial in nature. Although the importance of rehabilitation interventions after intensive care unit (ICU) discharge is universally recognized, evidence on feasibility and effectiveness of home-based rehabilitation programs is scarce and ambiguous. This study investigates the feasibility of an interdisciplinary rehabilitation program designed for patients with Post-Intensive Care Syndrome (PICS) who are discharged home. METHODS:A mixed method, non-randomized, prospective pilot feasibility study was performed with a 6-month follow-up, comparing the intervention (REACH) with usual care. REACH was provided by trained professionals and included a patient-centered, interdisciplinary approach starting directly after hospital discharge. Primary outcomes were patient safety, satisfaction, adherence, referral need and health care usage. Secondary outcomes, measured at 3 timepoints, were functional exercise capacity, self-perceived health status, health-related quality of life (HRQoL), return to work and psychotrauma. Risk of undernutrition was assessed at baseline. RESULTS:43 patients with a median mechanical ventilation duration of 8 (IQR:10) days, were included in the study and 79.1% completed 6-month follow-up. 19 patients received the intervention, 23 received usual care. Groups were similar for gender distribution and ICU length of stay. No adverse events occurred. REACH participants showed higher satisfaction with treatment and reported more allied health professional visits, while the usual care group reported more visits to medical specialists. Qualitative analysis identified positive experiences among REACH-professionals related to providing state-of-the-art interventions and sharing knowledge and expertise within an interprofessional network. Similar recovery was seen between groups on all secondary outcomes, but neither group reached reference values for HRQoL at 6 months. Larger return to work rates were seen in the REACH group. Prevalence of undernutrition at hospital discharge was high in both groups (> 80%), warranting the need for careful tuning of physical therapy and nutritional interventions. CONCLUSIONS:This study shows that providing early, home-based rehabilitation interventions for patients with PICS-related symptoms is feasible and perceived positively by patients and professionals. When provided in an interdisciplinary collaborative network state of the art, person-centered interventions can be tailored to individual needs potentially increasing patient satisfaction, adherence, and efficacy. Registered in the Dutch Trial register: NL7792: https://www.trialregister.nl/trial/7792 , registered 7-06-2019.