Postintensive Care Syndrome: Right Care, Right Now…and Later

The effects of intensive care unit-initiated transitional care interventions on elements of post-intensive care syndrome: A systematic review and meta-analysis

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).

Physical, Mental, and Cognitive Health Status of ICU Survivors Before ICU Admission: A Cohort Study

OBJECTIVES

Although patient's health status before ICU admission is the most important predictor for long-term outcomes, it is often not taken into account, potentially overestimating the attributable effects of critical illness. Studies that did assess the pre-ICU health status often included specific patient groups or assessed one specific health domain. Our aim was to explore patient's physical, mental, and cognitive functioning, as well as their quality of life before ICU admission.

DESIGN

Baseline data were used from the longitudinal prospective MONITOR-IC cohort study.

SETTING

ICUs of four Dutch hospitals.

PATIENTS

Adult ICU survivors (n = 2,467) admitted between July 2016 and December 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients, or their proxy, rated their level of frailty (Clinical Frailty Scale), fatigue (Checklist Individual Strength-8), anxiety and depression (Hospital Anxiety and Depression Scale), cognitive functioning (Cognitive Failure Questionnaire-14), and quality of life (Short Form-36) before ICU admission. Unplanned patients rated their pre-ICU health status retrospectively after ICU admission. Before ICU admission, 13% of all patients was frail, 65% suffered from fatigue, 28% and 26% from symptoms of anxiety and depression, respectively, and 6% from cognitive problems. Unplanned patients were significantly more frail and depressed. Patients with a poor pre-ICU health status were more often likely to be female, older, lower educated, divorced or widowed, living in a healthcare facility, and suffering from a chronic condition.

CONCLUSIONS

In an era with increasing attention for health problems after ICU admission, the results of this study indicate that a part of the ICU survivors already experience serious impairments in their physical, mental, and cognitive functioning before ICU admission. Substantial differences were seen between patient subgroups. These findings underline the importance of accounting for pre-ICU health status when studying long-term outcomes.

Reduced quality of life in ICU survivors - the story behind the numbers: A mixed methods study

PURPOSE

To gain insight into the daily functioning of ICU survivors who reported a reduced quality of life (QoL) one year after ICU admission.

MATERIALS AND METHODS

A two-phase mixed method study design. QoL was assessed using the SF-36 questionnaire before admission and after one year (Phase 1). Participants reporting a reduced QoL were invited for an in-depth interview (Phase 2). Interview data were coded thematically using the PROMIS framework.

RESULTS

Of the 797 participants, 173 (22%) reported a reduced QoL, of which 19 purposively selected patients were interviewed. In line with their questionnaire scores, most participants described their QoL as reduced. They suffered from physical, mental and/or cognitive problems, impacting their daily life, restricting hobbies, work, and social activities. A new balance in life, including relationships, had to be found. Some interviewees experienced no changes in their QoL; they were grateful for being alive, set new life priorities, and were able to accept their life with its limitations.

CONCLUSIONS

Reduction in QoL is due to physical, mental, and cognitive health problems, restricting participants what they want to do. However, QoL was not only affected by the critical illness, but also by factors including independency, comorbidity, and life events. Registration: NCT03246334 (clinical trials.gov).

Mixed-method research protocol: Development and evaluation of a nursing intervention in patients discharged from the intensive care unit

AIM

(a) To understand patients' lived experience at intensive care unit (ICU) discharge and (b) to evaluate the impact of a nursing empowerment intervention (NEI) on patients' anxiety and depression levels at ICU discharge.

DESIGN

A mixed-methods approach will be applied.

METHODS

In the qualitative phase, the hermeneutic phenomenological method will be used. Participants will be patients from three university hospitals who will be selected by purposive sampling. Data will be gathered through in-depth interviews and analysed using content analysis. The qualitative data obtained will be employed to develop the nursing intervention. Subsequently, a multicenter, parallel-group, experimental pre-test/post-test design with a control group will be used to measure the effectiveness of the nursing empowerment intervention in the quantitative phase by means of the Hospital Anxiety and Depression Scale (HADS). Simple random probabilistic sampling will include 172 patients in this phase.

Stressors in intensive cardiac care units: Patients' perceptions

BACKGROUND

Patients with acute coronary syndrome (ACS) are often admitted to intensive cardiac care units (ICCUs) to have their vital signs and ventricular function monitored. In most cases, they are conscious and bedbound, causing high stress and anxiety levels.

AIMS AND OBJECTIVES

To assess the stressors affecting patients admitted to ICCUs.

DESIGN

This is a cross-sectional study performed in a public hospital in São Paulo, Brazil.

METHODS

A sample of 100 patients with ACS admitted to an ICCU, after 24 hours of hospitalization, was recruited. Sociodemographic and clinical data were collected, and the Intensive Care Unit Stressor Assessment Scale (ICESS) was applied to investigate stressors. The ICESS' internal consistency was estimated by Cronbach's alpha, and the stressors were analysed by descriptive statistics, association tests, and correlation tests.

RESULTS

Most patients were male, married, and aged 51 to 60 years. The ICESS showed an excellent internal consistency. The mean score identified in patients pointed to a non-stressed to moderately stressed condition. The indicators considered to be more stressful were as follows: "Not knowing ICU length of stay," "Being unable to fulfil family roles," "Missing husband or wife," and "Loss of self-control."

CONCLUSIONS

Stress levels were considered to be non-stressful to moderately stressful. The main stressors were related to psychological distress and physical discomfort dimensions.

RELEVANCE TO CLINICAL PRACTICE

Mapping the main stressors of patients with coronary artery disease will allow health professionals to implement strategies to reduce them and consequently reduce their anxiety levels.

The Perme Mobility Index: A new concept to assess mobility level in patients with coronavirus (COVID-19) infection

Introduction

The Coronavirus Disease 2019 (COVID-19) outbreak is evolving rapidly worldwide. Data on the mobility level of patients with COVID-19 in the intensive care unit (ICU) are needed.

Objective

To describe the mobility level of patients with COVID-19 admitted to the ICU and to address factors associated with mobility level at the time of ICU discharge.

Methods

Single center, retrospective cohort study. Consecutive patients admitted to the ICU with confirmed COVID-19 infection were analyzed. The mobility status was assessed by the Perme Score at admission and discharge from ICU with higher scores indicating higher mobility level. The Perme Mobility Index (PMI) was calculated [PMI = ΔPerme Score (ICU discharge–ICU admission)/ICU length of stay]. Based on the PMI, patients were divided into two groups: “Improved” (PMI > 0) and “Not improved” (PMI ≤ 0).

Results

A total of 136 patients were included in this analysis. The hospital mortality rate was 16.2%. The Perme Score improved significantly when comparing ICU discharge with ICU admission [20.0 (7–28) points versus 7.0 (0–16) points; P < 0.001]. A total of 88 patients (64.7%) improved their mobility level during ICU stay, and the median PMI of these patients was 1.5 (0.6–3.4). Patients in the improved group had a lower duration of mechanical ventilation [10 (5–14) days versus 15 (8–24) days; P = 0.021], lower hospital length of stay [25 (12–37) days versus 30 (11–48) days; P < 0.001], and lower ICU and hospital mortality rate. Independent predictors for mobility level were lower age, lower Charlson Comorbidity Index, and not having received renal replacement therapy.

Conclusion

Patients’ mobility level was low at ICU admission; however, most patients improved their mobility level during ICU stay. Risk factors associated with the mobility level were age, comorbidities, and use of renal replacement therapy.

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

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

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00796-1.

Severe covid-19 pneumonia: pathogenesis and clinical management

Severe covid-19 pneumonia has posed critical challenges for the research and medical communities. Older age, male sex, and comorbidities increase the risk for severe disease. For people hospitalized with covid-19, 15-30% will go on to develop covid-19 associated acute respiratory distress syndrome (CARDS). Autopsy studies of patients who died of severe SARS CoV-2 infection reveal presence of diffuse alveolar damage consistent with ARDS but with a higher thrombus burden in pulmonary capillaries. When used appropriately, high flow nasal cannula (HFNC) may allow CARDS patients to avoid intubation, and does not increase risk for disease transmission. During invasive mechanical ventilation, low tidal volume ventilation and positive end expiratory pressure (PEEP) titration to optimize oxygenation are recommended. Dexamethasone treatment improves mortality for the treatment of severe and critical covid-19, while remdesivir may have modest benefit in time to recovery in patients with severe disease but shows no statistically significant benefit in mortality or other clinical outcomes. Covid-19 survivors, especially patients with ARDS, are at high risk for long term physical and mental impairments, and an interdisciplinary approach is essential for critical illness recovery.

Cardiorespiratory and skeletal muscle damage due to COVID-19: making the urgent case for rehabilitation

INTRODUCTION

It has become increasingly evident that COVID-19 contributes to multiorgan pathophysiology. The systemic inflammatory response increases both pro-inflammatory cytokine and chemokine levels, leading to immune dysregulation and increasing the likelihood of incurring cardiac and pulmonary injuries.

AREAS COVERED

Longer periods of hospitalization (~20 days) increase susceptibility to ICU-acquired muscle weakness and deconditioning, which decreases muscle function and functional capacity. These conditions affect the quality of life in the post-COVID-19 period and require multi-disciplinary approaches to rehabilitate the cardiopulmonary and musculoskeletal systems of these patients. In this context, this narrative review, which included articles published in the Embase, PEDro and PubMed databases up to December 2020, is focused on discussing the essential role of exercise and rehabilitation health professionals in the COVID-19 recovery process, from hospitalization to hospital discharge, addressing strategies for professionals to mitigate the cardiac and pulmonary impairments associated with hospitalization to home or ambulatory rehabilitation, purposing ways to conduct rehabilitation programs to restore their functional status and quality of life after the infection.

EXPERT OPINION

In the current environment, these findings further point to the vital role of rehabilitation health professionals in the coming years and the urgent need to develop strategies to assist COVID-19 survivors.

A comparison of standard occupational therapy versus early enhanced occupation-based therapy in a medical/surgical intensive care unit: study protocol for a single site feasibility trial (EFFORT-ICU)

BACKGROUND

Admissions to intensive care units (ICUs) are increasing due to an ageing population, and rising incidence of cardiac and respiratory disease. With advances in medical care, more patients are surviving an initial stay in critical care; however, they can experience ongoing health and cognitive limitations that may influence return to baseline function up to a year post-admission. Recent research has focused on the introduction of early rehabilitation within the ICU to reduce long-term physical and cognitive complications. The aim of this study is to explore the feasibility and impact of providing early enhanced occupation-based therapy, including cognitive stimulation and activities of daily living, to patients in intensive care.

METHODS

This study involves a single site randomised-controlled feasibility trial comparing standard occupational therapy care to an early enhanced occupation-based therapy. Thirty mechanically ventilated ICU patients will be recruited and randomly allocated to the intervention or control group. The primary outcome measure is the Functional Independence Measure (FIM), and secondary measures include the Modified Barthel Index (MBI), Montreal Cognitive Assessment (MoCA), grip strength, Hospital Anxiety and Depression Scale (HADS) and Short-Form 36 Health survey (SF-36). Measures will be collected by a blind assessor at discharge from intensive care, hospital discharge and a 90-day follow-up. Daily outcome measures including the Glasgow Coma Scale (GCS), Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Measure for intensive care units (CAM-ICU) will be taken prior to treatment. Participants in the intervention group will receive daily a maximum of up to 60-min sessions with an occupational therapist involving cognitive and functional activities such as self-care and grooming. At the follow-up, intervention group participants will be interviewed to gain user perspectives of the intervention. Feasibility data including recruitment and retention rates will be summarised descriptively. Parametric tests will compare outcomes between groups. Interview data will be thematically analysed.

DISCUSSION

This trial will provide information about the feasibility of investigating how occupational therapy interventions in ICU influence longer term outcomes. It seeks to inform the design of a phase III multicentre trial of occupational therapy in critical care general medical intensive care units.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000374268 ; prospectively registered on 13 March 2018/ https://www.anzctr.org.au Trial funding: Metro South Health Research Support Scheme Postgraduate Scholarship.

Prevalence of post-intensive care syndrome among Japanese intensive care unit patients: a prospective, multicenter, observational J-PICS study

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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03501-z.

[Psychotraumatological aspects in intensive care medicine]

In the context of intensive care medicine, patients, their relatives, and more infrequently members of the ICU team can be affected by potential trauma. Acute stress disorder often results. Psychological symptoms of critically ill patients should therefore be regularly screened in a standardized manner in order to be able to identify and treat patients with a high symptom burden. Some traumatic stressors in intensive care medicine can be reduced using trauma-sensitive communication. Psychological and psychotherapeutic interventions can complement this basic care. High quality communication with relatives contributes to a risk reduction with regard to their subsequent psychological stress. On the part of the ICU team, stress should be differentiated from potentially traumatizing events and both problem areas should be dealt with preventively. After experiencing a traumatic event during work, a procedure analogous to physical work accidents is recommended.

Enhancing Family-Centered Care in Cardiothoracic Surgery

The psychological impact of critical illness is far reaching, affecting patients and their loved ones. Family members face a multitude of stressors, ranging from concerns about death or permanent disability to stress over health care costs and lost wages. Patients are at risk for developing post-intensive care syndrome. Professional groups and patient safety organizations have crafted family-centered care (FCC) models that support hospitalized patients and their families. There is a paucity of data on use of FCC in cardiothoracic intensive care units. This article discusses FCC models and why they are beneficial to the needs of families of postoperative cardiothoracic surgery patients.

Distorted Memories and Related Factors in ICU Patients

This study aimed to examine the relationship between memory status of and factors related to patients in the intensive care unit (ICU) using a cross-sectional study design. Participants were adult patients who were admitted to the general ICUs for more than 48 hours. One week after ICU discharge, a survey on memory distortion was conducted. Overall, 133 patients were included, of whom 51.1% reported distorted memories. Among them, 15.0% had memory loss; 48.1% had unrealistic experiences; 27.8% recalled confusion, panic, anxiety, and discomfort during their ICU stay; and 9% had traumatic experiences. Multiple logistic regression analyses revealed that memory loss was associated with an operation, and a significant association was observed between traumatic memory and pain. Opioid use may have a protective effect against memory loss. These results suggest the importance of relieving pain and preserving true memories during ICU treatment.

[Fighting against COVID-19: clinical activities of spanish rehabilitation physicians: A cross-sectional study]

Objetivo

El objetivo de este estudio es analizar el impacto y la organización tanto asistencial como docente en los Servicios de Medicina Física y Rehabilitación de España ante el nuevo y cambiante escenario debido a la pandemia por la COVID-19.

Métodos

Se realiza una encuesta dirigida a los tutores de los Servicios de Rehabilitación. Un total de 31 preguntas divididas en 6 apartados: información general de los Servicios, adaptación del Servicio durante el periodo COVID, labor asistencial de los médicos rehabilitadores, abordaje rehabilitador de pacientes COVID, consecuencia de la pandemia sobre la salud de los rehabilitadores y labores de tutoría durante ese periodo.

Resultados

Se recibieron un total de 54 encuestas. Casi la mitad de los Servicios cancelaron todas las consultas presenciales (40%) y las salas de terapias se destinaron a camas de pacientes COVID (48%). En 30 hospitales (55,6%) los facultativos han trabajado en plantas COVID. La gran mayoría de los Servicios han elaborado material gráfico y audiovisual con ejercicios, así como protocolos de derivación y tratamiento rehabilitador de pacientes COVID ingresados. Casi la mitad de los Servicios encuestados han tenido algún caso de ansiedad en el personal médico. Las labores de tutoría se han anulado (40,7%) o disminuido (35,2%).

Conclusiones

La organización de los Servicios de Rehabilitación para hacer frente a la pandemia ha sido similar en todo el territorio español. La respuesta de los Servicios a la crisis sanitaria ha visualizado la versatilidad de trabajo de los médicos rehabilitadores.

Developing and testing a nurse-led intervention to support bereavement in relatives in the intensive care (BRIC study): a protocol of a pre-post intervention study

BACKGROUND

When a patient is approaching death in the intensive care unit (ICU), patients' relatives must make a rapid transition from focusing on their beloved one's recovery to preparation for their unavoidable death. Bereaved relatives may develop complicated grief as a consequence of this burdensome situation; however, little is known about appropriate options in quality care supporting bereaved relatives and the prevalence and predictors of complicated grief in bereaved relatives of deceased ICU patients in the Netherlands. The aim of this study is to develop and implement a multicomponent bereavement support intervention for relatives of deceased ICU patients and to evaluate the effectiveness of this intervention on complicated grief, anxiety, depression and posttraumatic stress in bereaved relatives.

METHODS

The study will use a cross-sectional pre-post design in a 38-bed ICU in a university hospital in the Netherlands. Cohort 1 includes all reported first and second contact persons of patients who died in the ICU in 2018, which will serve as a pre-intervention baseline measurement. Based on existing policies, facilities and evidence-based practices, a nurse-led intervention will be developed and implemented during the study period. This intervention is expected to use 1) communication strategies, 2) materials to make a keepsake, and 3) a nurse-led follow-up service. Cohort 2, including all bereaved relatives in the ICU from October 2019 until March 2020, will serve as a post-intervention follow-up measurement. Both cohorts will be performed in study samples of 200 relatives per group, all participants will be invited to complete questionnaires measuring complicated grief, anxiety, depression and posttraumatic stress. Differences between the baseline and follow-up measurements will be calculated and adjusted using regression analyses. Exploratory subgroup analyses (e.g., gender, ethnicity, risk profiles, relationship with patient, length of stay) and exploratory dose response analyses will be conducted.

DISCUSSION

The newly developed intervention has the potential to improve the bereavement process of the relatives of deceased ICU patients. Therefore, symptoms of grief and mental health problems such as depression, anxiety and posttraumatic stress, might decrease.

TRIAL REGISTRATION

Netherlands Trial Register Registered on 27/07/2019 as NL 7875, www.trialregister.nl.

[Psychotraumatological aspects in intensive care medicine]

In the context of intensive care medicine, patients, their relatives, and more infrequently members of the ICU team can be affected by potential trauma. Acute stress disorder often results. Psychological symptoms of critically ill patients should therefore be regularly screened in a standardized manner in order to be able to identify and treat patients with a high symptom burden. Some traumatic stressors in intensive care medicine can be reduced using trauma-sensitive communication. Psychological and psychotherapeutic interventions can complement this basic care. High quality communication with relatives contributes to a risk reduction with regard to their subsequent psychological stress. On the part of the ICU team, stress should be differentiated from potentially traumatizing events and both problem areas should be dealt with preventively. After experiencing a traumatic event during work, a procedure analogous to physical work accidents is recommended.

Influences of the culture of science on nursing knowledge development: Using conceptual frameworks as nursing philosophy in critical care nursing

Nursing knowledge development and application are influenced by numerous factors within the context of science and practice. The prevailing culture of science along with an evolving context of increasingly technological environments and rationalization within health care impacts both the generation of nursing knowledge and the practice of nursing. The effects of the culture of science and the context of nursing practice may negatively impact the structure and application of nursing knowledge, how nurses practice, and how nurses understand the patients and families for whom they care. Specifically, the nature of critical care and its highly technical environment make critical care nursing especially vulnerable to these potentially negative influences. The influences of the culture of science and the increasingly technical practice context may result in an overreliance on the natural sciences to guide critical care nursing actions and an associated marginalization of the caring relationship in critical care nursing practice. Within this environment, nursing philosophy may not be foundational to nursing actions; rather, the dominant culture of science and the rationalization of health care may be informing nursing practice. As such, the ideology and goals of nursing may not be central to the practice of critical care nursing. The purpose of this paper is to explore the influence of the culture of science on the development of nursing knowledge and theory. Further, we aim to describe the value of using conceptual frameworks, such as Roy's Adaptation Model, as a nursing philosophy to influence the development of person-centred nursing knowledge and theory to inform critical care nursing practice as it related to the care of patients and families. In doing so, nursing philosophy is situated as foundational for nursing actions.

Nutrition-related symptoms in adult survivors of critical illness who are eating orally: a scoping review protocol

OBJECTIVE

This review will explore and map the current literature on the nutritional impact of symptoms reported by adult survivors of critical illness who are eating orally after discharge from the intensive care unit (ICU).

INTRODUCTION

Survivors of critical care often experience ICU-acquired weakness and poor functional recovery. It is plausible that nutrition interventions throughout their recovery could improve outcomes for these patients. Although a growing number of studies aim to explore the effect of nutrition delivered in the early phases of critical illness, this is also important post-ICU discharge, particularly in already nutritionally compromised patients presenting with muscle loss and fatigue. Therefore, the development of targeted nutrition interventions will be informed by a comprehensive insight into the physiological, physical, or psychological difficulties that critically ill patients experience after ICU discharge, which may impede oral intake.

INCLUSION CRITERIA

This review will consider primary research studies with adult patients 18 years and older, who are in the recovery phase after being critically ill, and eating orally. Studies must report on any symptoms related to the ability to eat, or represent nutrition inadequacy or utilization.

METHODS

A scoping review will be conducted in accordance with JBI methodology using a three-step search strategy of MEDLINE, Embase, CINAHL, AMED, Web of Science, Cochrane Database of Systematic Reviews, and JBI Evidence-based Practice Database to obtain primary research studies that meet the inclusion criteria. Duplicates will be removed, and study selection and data extraction will be conducted and cross-checked by two independent reviewers. Data synthesis will involve presenting the results in tabular form.

[The war in my head : A psychotraumatological case report after a prolonged intensive care unit stay]

Intensive care treatment is proven to be associated with patients' mental symptoms. There is a correlation between acute stress and psychological sequelae, which has not yet been sufficiently theoretically substantiated. This case report illustrates the development of mental symptoms during and after intensive care treatment with reference to a psychotraumatological model. Above all, memories that are not related to reality but are associated with fear of death are potentially traumatic. A re-evaluation of these memories can help to prevent psychological sequelae. Psychoeducation, conversation with the staff of the intensive care unit (ICU) and the ICU diary are helpful instruments in this process. Continuous psychological care should be provided if acute psychological stress occurs during intensive care medical treatment.

Factors associated with ABCDE bundle adherence in critically ill adults requiring mechanical ventilation: An observational design

OBJECTIVE

To identify factors associated with the ABCDEF bundle (Assess, prevent, and manage pain, Both, spontaneous awakening and breathing trials, Choice of sedation/analgesia, Delirium assess, prevent and manage, Early mobility/exercise and Family engagement/empowerment) adherence, in critically ill patients during the first 96 hours of mechanical ventilation.

DESIGN

Observational study using electronic health record data.

SETTING

15 intensive care units located in seven community hospitals in a western United States health system.

PATIENTS

977 adult patients who were on mechanical ventilation for greater than 24 hours and admitted to an intensive care unit over six months.

MEASUREMENTS AND MAIN RESULTS

Multiple regression analysis was used to examine factors contributing to bundle adherence while adjusting for severity of illness, days on mechanical ventilation, hospital site and time elapsed. ABCDEF bundle adherence was higher in patients on mechanical ventilation for less than 48 hours (p = 0.01), who received continuous sedation for less than 24 hours (p < 0.001), admitted from skilled nursing facilities (p < 0.05), and over the course of the six-month study period (p < 0.01). Bundle adherence was significantly lower for Hispanic patients (p < 0.01).

CONCLUSIONS

Our study identified potentially modifiable factors that could improve the team's performance of the ABCDEF bundle in patients requiring mechanical ventilation.

A Progressive Early Mobilization Program Is Significantly Associated With Clinical and Economic Improvement: A Single-Center Quality Comparison Study

OBJECTIVES

To determine whether a progressive early mobilization protocol improves patient outcomes, including in-hospital mortality and total hospital costs.

DESIGN

Retrospective preintervention and postintervention quality comparison study.

SETTINGS

Single tertiary community hospital with a 12-bed closed-mixed ICU.

PATIENTS

All consecutive patients 18 years old or older were eligible. Patients who met exclusion criteria or were discharged from the ICU within 48 hours were excluded. Patients from January 2014 to May 2015 were defined as the preintervention group (group A) and from June 2015 to December 2016 was the postintervention group (group B).

INTERVENTION

Maebashi early mobilization protocol.

MEASUREMENTS AND MAIN RESULTS

Group A included 204 patients and group B included 187 patients. Baseline characteristics evaluated include age, severity, mechanical ventilation, and extracorporeal membrane oxygenation, and in group B additional comorbidities and use of steroids. Hospital mortality was reduced in group B (adjusted hazard ratio, 0.25; 95% CI, 0.13-0.49; p < 0.01). This early mobilization protocol is significantly associated with decreased mortality, even after adjusting for baseline characteristics such as sedation. Total hospital costs decreased from $29,220 to $22,706. The decrease occurred soon after initiating the intervention and this effect was sustained. The estimated effect was $-5,167 per patient, a 27% reduction. Reductions in ICU and hospital lengths of stay, time on mechanical ventilation, and improvement in physical function at hospital discharge were also seen. The change in Sequential Organ Failure Assessment score and Sequential Organ Failure Assessment score at ICU discharge were significantly reduced after the intervention, despite a similar Sequential Organ Failure Assessment score at admission and at maximum.

CONCLUSIONS

In-hospital mortality and total hospital costs are reduced after the introduction of a progressive early mobilization program, which is significantly associated with decreased mortality. Cost savings were realized early after the intervention and sustained. Further prospective studies to investigate causality are warranted.

A multisite study of nurse-reported perceptions and practice of ABCDEF bundle components

OBJECTIVES

ABCDEF bundle implementation in the Intensive Care Unit (ICU) is associated with dose dependent improvements in patient outcomes. The objective was to compare nurse attitudes about the ABCDEF bundle to self-reported adherence to bundle components.

RESEARCH METHODOLOGY/DESIGN

Cross-sectional study.

SETTING

Nurses providing direct patient care in 28 ICUs within 18 hospitals across the United States.

MAIN OUTCOME MEASURES

53-item survey of attitudes and practice of the ABCDEF bundle components was administered between November 2011 and August 2015 (n = 1661).

RESULTS

We did not find clinically significant correlations between nurse attitudes and adherence to Awakening trials, Breathing trials, and sedation protocol adherence (r_s = 0.05-0.28) or sedation plan discussion during rounds and Awakening and Breathing trial Coordination (r_s = 0.19). Delirium is more likely to be discussed during rounds when ICU physicians and nurse managers facilitate delirium reduction (r_s = 0.27-0.36). Early mobilization is more likely to occur when ICU physicians, nurse managers, staffing, equipment, and the ICU environment facilitate early mobility (r_s = 0.36-0.47). Physician leadership had the strongest correlation with reporting an ICU environment that facilitates ABCDEF bundle implementation (r_s = 0.63-0.74).

CONCLUSIONS

Nurse attitudes about bundle implementation did not predict bundle adherence. Nurse manager and physician leadership played a large role in creating a supportive ICU environment.

Implementation of a Patient and Family-Centered Intensive Care Unit Peer Support Program at a Veterans Affairs Hospital

Peer support is a novel strategy to mitigate postintensive care syndrome and postintensive care syndrome-family. This project implemented a peer support program to address postintensive care syndrome for patients and family members. Using a free-flow, unstructured format, a chaplain, social worker, nurse, and intensive care unit survivor led veterans and loved ones in discussion of intensive care unit experiences, fears, and the challenges of recovery. Evaluations indicated group participation is beneficial for emotional support, coping, and understanding common situations related to prolonged intensive care unit stay. A majority reported they would strongly recommend group participation to a friend.

Management of the Patient with Malignant Hemispheric Stroke

Malignant hemispheric stroke occurs in 10% of ischemic strokes and has one of the highest mortality and morbidity rates. This stroke, also known as malignant middle cerebral artery stroke, may cause ischemia to an entire hemisphere causing edema, herniation, and death. A collaborative interdisciplinary team approach is needed to manage these complex stroke patients. The nurse plays a vital role in bedside management and support of the patient and family through this complex course of care. This article discusses malignant middle cerebral artery stroke pathophysiology, techniques to predict patients at risk for herniation, collaborative care strategies, and nursing care.

The Experience of Acute Mechanical Ventilation From the Patient's Perspective

BACKGROUND

The Pain, Agitation, and Delirium guidelines influenced practice to support targeted, light sedation for the mechanically ventilated patient. This practice is associated with improved clinical outcomes, but it remains unclear how it impacts the patient experience.

OBJECTIVE

The objective was to determine the pervasive patient experience components and how the experience may have been influenced by targeted, light sedation practices.

METHODS

A prospective observational study using mixed methodology and a convenience sample was conducted after institutional review board approval was obtained. Inclusion criteria were the following: acute mechanical ventilation of less than 14 days, 18 years or older and able to provide consent, English speaking, and delirium-free. Exclusion criteria were the presence of delirium or intravenous opioids/sedatives within 24 hours prior to the interview. The quantitative component included simple yes or no questions and identification of quantitative adjectives describing the mechanical ventilation experience. Every 10th patient was invited to participate in an expanded qualitative interview.

RESULTS

Data were collected for 12 months with a total sample size of 130 patients participating in the quantitative component and a subset of 15 patients also participating in the qualitative interview. Sixty percent of the total sample consisted of cardiothoracic surgery patients, and 40% were mixed intensive care unit patient populations. Descriptive statistics include the following averaged values: Richmond Agitation Sedation Scale scores -1.7 throughout mechanical ventilation, aged 59.9 years, days mechanically ventilated 1.4, intensive care unit length of stay 4.6 days, and Acute Physiology and Chronic Health Evaluation II score 16.1. The most significant finding was that 56.2% of patients who could not communicate reported feeling afraid, whereas 32.5% of those who could communicate reported feeling afraid (P < .027). The themes identified in the qualitative component of the study reinforced these quantitative findings; 10 of the 15 patients interviewed reported experiencing fear, and all of the patients reported issues with communication.

DISCUSSION

The clinical implications of this research study primarily affect critical care nursing. Changes in nursing practice can address these findings to improve and more effectively acknowledge the patient experience.

Cut-Off Values of the Post-Intensive Care Syndrome Questionnaire for the Screening of Unplanned Hospital Readmission within One Year

PURPOSE

This study aimed to assign weights for subscales and items of the Post-Intensive Care Syndrome questionnaire and suggest optimal cut-off values for screening unplanned hospital readmissions of critical care survivors.

METHODS

Seventeen experts participated in an analytic hierarchy process for weight assignment. Participants for cut-off analysis were 240 survivors who had been admitted to intensive care units for more than 48 hours in three cities in Korea. We assessed participants using the 18-item Post-Intensive Care Syndrome questionnaire, generated receiver operating characteristic curves, and analysed cut-off values for unplanned readmission based on sensitivity, specificity, and positive likelihood ratios.

RESULTS

Cognitive, physical, and mental subscale weights were 1.13, 0.95, and 0.92, respectively. Incidence of unplanned readmission was 25.4%. Optimal cut-off values were 23.00 for raw scores and 23.73 for weighted scores (total score 54.00), with an area of under the curve (AUC) of .933 and .929, respectively. There was no significant difference in accuracy for original and weighted scores.

CONCLUSION

The optimal cut-off value accuracy is excellent for screening of unplanned readmissions. We recommend that nurses use the Post-Intensive Care Syndrome Questionnaire to screen for readmission risk or evaluating relevant interventions for critical care survivors.

[Psychological care in German intensive care units : Results of a survey among the members of the German Interdisciplinary Association for Intensive Care and Emergency Medicine]

BACKGROUND

Psychological care should be provided in intensive care units (ICUs) because of the proven mental symptoms of patients and relatives. Even physicians and nurses can benefit from a corresponding care structure. Knowledge is lacking whether and how psychological care for patients and relatives as well as support for staff in German ICUs is implemented. For this reason, a survey was conducted among the members of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) to gain an overview of the current structures and the need for psychological support.

METHODS

The members of DIVI were invited to participate in a web-based survey. A total of 226 physicians and nurses took part in the survey. Analysis included statistics and group comparisons with Χ² methods.

RESULTS

In all care areas, psychological care of patients, relatives, and support for staff, respondents indicated a significant undersupply and expressed the need for improved care. A model which provides consular or team-integrated support based on the level of care is conceivable.

DISCUSSION

The current state of psychological care in German ICUs does not cover the existing need. Consequently the development of concepts and the beginning of discussions on how appropriate psychological care can be implemented in the future is necessary.

Skeletal Muscle Index at Intensive Care Unit Admission Is a Predictor of Intensive Care Unit-Acquired Weakness in Patients With Sepsis

Background

Intensive care unit-acquired weakness (ICU-AW) can be diagnosed using the Medical Research Council (MRC) score. However, such scoring may not be possible in ICU patients who may be sedated or delirious or have encephalopathy. Currently, a quantitative assessment of the cross-sectional area of the muscle is available to assess changes in skeletal muscle mass using computed tomography (CT) images. This assessment calculates the skeletal muscle index (SMI) (cm²/m²) by dividing the cross-sectional area (cm²) of the skeletal muscle at the level of the third lumbar vertebra by the square of the patient’s height (m²) on CT. This study assessed the effectiveness of SMI, as measured by abdominal CT scans, in predicting the onset of ICU-AW in patients with sepsis admitted to the ICU.

Methods

We examined septic ICU patients admitted to the Niigata University Hospital ICU during 2012 - 2017 under mechanical ventilation. Patients were retrospectively divided into two groups by MRC score at ICU discharge: group AW comprised patients with an MRC score < 48, and group non-AW (NAW) comprised the remaining patients. Clinicopathological factors at ICU admission such as age, gender, underlying disease, body mass index, and SMI were compared between the two groups. Statistical analyses were performed using the Mann-Whitney U test, Fisher’s exact test, receiver operator characteristic (ROC) analysis and multivariate analysis.

Results

A total of 31 septic patients were examined, and 23 patients met the criteria for ICU-AW. The prevalence of women was significantly higher in group AW (P < 0.05). All clinical factors, except for gender, were not significantly different between the two groups. SMI was significantly lower in group AW than in group NAW (P < 0.05). ROC analysis revealed that the cut-off value of SMI for predicting ICU-AW was 44.1, and the multivariate analysis revealed that only low SMI was a significant factor in predicting ICU-AW (P < 0.05).

Conclusions

Our results show that SMI measurement at ICU admission is a valid predictive factor for ICU-AW progression in septic patients.

Inter-facility transfers for advanced critical care services: Impacts on rural families

AIMS AND OBJECTIVES

The aim of this article is to provide an integrative review of rural family members' experiences of a relative's inter-facility transfer to an urban tertiary care centre for advanced critical care services.

BACKGROUND

Although there is an increasing awareness of the negative consequences of a relative's critical illness for family members, there has been limited research conducted on the impacts of this experience for families of patients in rural settings who require an inter-facility transfer for advanced services.

SEARCH STRATEGY

The search strategy for this review was framed by the study purpose, research question, and a conceptual structure of key constructs. Databases and reference lists were electronically and manually searched.

INCLUSION AND EXCLUSION CRITERIA

Articles were included if they were research articles, available in English, and focused on family members' experiences of inter-facility transfer during critical illness. Articles focusing on critical care transfers within a single urban setting, elective transfers undertaken for patient or family preference, transfers not associated with critical illness, and systematic or scoping reviews were excluded.

CONCLUSION

Stress and anxiety are central to the rural family members' experience of this phenomenon. These constructs are influenced by modifiable factors, including the actions of health care providers, the financial burden associated with the transfer, the family members' physical proximity to the patient, and their access to information and support networks. Further research is required to explore potential short- and long-term consequences of this experience and the experience of family members who are left behind and to develop and test interventions to support families.

RELEVANCE TO CLINICAL PRACTICE

This review highlights the concern that health care providers frequently misunderstand the needs of family members who are experiencing this phenomenon. Through a better understanding of this phenomenon, health care providers will be better positioned to effectively support these individuals during this unique experience.

Healthcare trajectories before and after critical illness: population-based insight on diverse patients clusters

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.

Application of Telemedicine Technology to Facilitate Diagnosis of Pediatric Postintensive Care Syndrome

Background: Postintensive care syndrome (PICS) is well-defined in the adult literature but has not received much attention in pediatrics. Introduction: We sought to use a telemedicine platform for the characterization of PICS by creating a convenient and effective virtual follow-up clinic. Materials and Methods: Prospective single-center study in a pediatric intensive care unit (ICU) of patients aged 4-17 years who underwent any invasive procedures while admitted to the ICU. Parents completed the Weiss Functional Impairment Rating Scale (WFIRS) based on baseline behaviors before ICU admission, with the scale readministered at 1 week, 1 month, and 3 months postdischarge via secure telehealth platform. Patients with a WFIRS baseline raw score of 10 or an interval increase of 2 were referred to psychiatry for evaluation and treatment. Results: Fifty patients were enrolled. Risk factors for PICS included number of procedural interventions, length of pediatric ICU stay, number of specialty consults, sex, race, and duration of sedation/airway instrumentation. In univariate analysis, age appeared to be the only statistically significant factor associated with the development of PICS. Variables associated with a higher change in WFIRS score showed a statistically significant correlation with the number of procedures completed, the number of specialists involved, and the need for a psychiatric referral. Only 34% of total telemedicine follow-ups were completed. Discussion: There is an association between age and the development of PICS and between change in WFIRS score and number of procedures, specialist involved, and psychiatric referral. Conclusions: The use of telemedicine did not result in an improved follow-up rate when compared to outpatient clinic studies.

Postintensive Care Syndrome in Pediatric Critical Care Survivors: Therapeutic Options to Improve Outcomes After Acquired Brain Injury

PURPOSE OF REVIEW

Children surviving the pediatric intensive care unit (PICU) with neurologic illness or injury have long-term morbidities in physical, cognitive, emotional, and social functioning termed postintensive care syndrome (PICS). In this article, we review acute and longitudinal management strategies available to combat PICS in children with acquired brain injury.

RECENT FINDINGS

Few intervention studies in this vulnerable population target PICS morbidities. Small studies show promise for both inpatient- and outpatient-initiated therapies, mainly focusing on a single domain of PICS and evaluating heterogeneous populations. While evaluating the effects of interventions on longitudinal PICS outcomes is in its infancy, longitudinal clinical programs targeting PICS are increasing. A multidisciplinary team with inpatient and outpatient presence is necessary to deliver the holistic integrated care required to address all domains of PICS in patients and families. While PICS is increasingly recognized as a chronic problem in PICU survivors with acquired brain injury, few interventions have targeted PICS morbidities. Research is needed to improve physical, cognitive, emotional, and social outcomes in survivors and their families.

Post-intensive care syndrome: its pathophysiology, prevention, and future directions

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: impact, prevention, and management

Millions of people worldwide have survived an admission to the intensive care unit (ICU), and the number of survivors is growing [1]. While these patients have survived a life-threatening illness, most survivors suffer important long-term complications [2]. Post-intensive care syndrome (PICS) is a term that describes the cognitive, psychological, physical and other consequences that plague ICU survivors [3, 4]. Our aim is to discuss the prevalence, risk factors, impact, prevention and management of PICS.

Post-intensive care syndrome (PICS): inpatient prevention and outpatient recognition are essentialhttp://bit.ly/2GCgz1q

Early mobilisation in mechanically ventilated patients: a systematic integrative review of definitions and activities

Background

Mechanically ventilated patients often develop muscle weakness post-intensive care admission. Current evidence suggests that early mobilisation of these patients can be an effective intervention in improving their outcomes. However, what constitutes early mobilisation in mechanically ventilated patients (EM-MV) remains unclear. We aimed to systematically explore the definitions and activity types of EM-MV in the literature.

Methods

Whittemore and Knafl’s framework guided this review. CINAHL, MEDLINE, EMBASE, PsycINFO, ASSIA, and Cochrane Library were searched to capture studies from 2000 to 2018, combined with hand search of grey literature and reference lists of included studies. The Critical Appraisal Skills Programme tools were used to assess the methodological quality of included studies. Data extraction and quality assessment of studies were performed independently by each reviewer before coming together in sub-groups for discussion and agreement. An inductive and data-driven thematic analysis was undertaken on verbatim extracts of EM-MV definitions and activities in included studies.

Results

Seventy-six studies were included from which four major themes were inferred: (1) non-standardised definition, (2) contextual factors, (3) negotiated process and (4) collaboration between patients and staff. The first theme indicates that EM-MV is either not fully defined in studies or when a definition is provided this is not standardised across studies. The remaining themes reflect the diversity of EM-MV activities which depends on patients’ characteristics and ICU settings; the negotiated decision-making process between patients and staff; and their interdependent relationship during the implementation.

Conclusions

This review highlights the absence of an agreed definition and on what constitutes early mobilisation in mechanically ventilated patients. To advance research and practice an agreed and shared definition is a pre-requisite.

The Lifetime Effects of Injury: Postintensive Care Syndrome and Posttraumatic Stress Disorder

Postintensive care syndrome (PICS) is a heterogeneous syndrome marked by physical, cognitive, and mental health impairments experienced by critical care survivors. It is a syndrome that bears significant human and health care costs. Additional research is needed to identify risk factors and diagnostic, preventative, and treatment strategies for PICS. Trauma intensive care unit patients are particularly vulnerable to posttraumatic stress disorder, which shares some of the adverse long-term consequences of PICS and also requires additional research into effective preventative and management strategies.

Long-term quality of life in patients treated with extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock

Objective:

The aim of our study was to explore long-term health-related quality of life (HRQOL) and incidence of post-traumatic stress disorder (PTSD) in extracorporeal membrane oxygenation (ECMO) survivors.

Methods:

Single-center prospective follow-up study. All patients in whom ECMO was initiated due to refractory cardiogenic shock between 2009 and 2014 were included in the study. We used Medical Outcomes Study 36-Item Short-Form Health Survey to evaluate HRQOL and IES-R questionnaire to assess incidence of PTSD.

Results:

Sixty-nine patients were treated with venoarterial (VA) ECMO during the study period. Nineteen patients survived until hospital discharge and 15 patients were alive at the study cut-off point in June 2017; mean follow-up time was 70.6 ± 10 months. The average Physical Component Summary and Mental Component Summary scores amongst long-term survivors were 46.1 ± 7 and 47.1 ± 8, respectively. PTSD was evident in 4 out of 15 participants.

Conclusions:

Despite the complex clinical course and prolonged recovery, ECMO survivors achieved satisfactory levels of both mental and physical recovery, which were comparable to the age- and pathology-adjusted population means.