Quality of life after complicated elective surgery requiring intensive care

Intensive Care Unit-acquired Neuromuscular Weakness: A Prospective Study on Incidence, Clinical Course, and Outcomes

Background

Neuromuscular weakness may manifest subsequent to critical illness in intensive care unit (ICU) patients. This weakness termed as “ICU-acquired weakness” (ICUAW) has a significant bearing on the length of mechanical ventilation, duration of ICU stays, long-term disability, and survival rate. Early identification of ICUAW helps in planning appropriate strategies, as well as in predicting the prognosis and long-term outcomes of these patients.

Aims and objectives

To identify the incidence of new-onset neuromuscular weakness developing among patients admitted in the ICU (ICUAW) and study its clinical course and impact on the duration of ICU stay.

Methods

This prospective observational study evaluated patients admitted to the ICU over a period of 1 year and 3 months (November 1, 2015, to January 31, 2017). All patients fulfilling the inclusion and exclusion criteria were evaluated with the Medical Research Council (MRC) score for muscle strength. Patients with an average score <4 were diagnosed with ICUAW. Included patients were examined on alternate days to study the clinical progression of the weakness till ICU discharge or death of the patient. The duration of ICU stay was noted.

Results and conclusion

The study revealed a significant association of ICUAW with age, Acute Physiology And Chronic Health Evaluation (APACHE II) Score, duration of mechanical ventilation, and ICU mortality. The incidence of the weakness was found to be 7.83% among the patients who survived and 50% among those patients who did not survive critical illness.

How to cite this article

Baby S, George C, Osahan NM. Intensive Care Unit-acquired Neuromuscular Weakness: A Prospective Study on Incidence, Clinical Course, and Outcomes. Indian J Crit Care Med 2021;25(9):1006–1012.

Measuring Acute Pain Over Time in the Critically Ill Using the Multidimensional Objective Pain Assessment Tool (MOPAT)

BACKGROUND

A valid and reliable instrument is needed to assess acute pain in critically ill patients unable to self-report and who may be transitioning between critical care and other settings.

AIM

To examine the reliability, validity, and clinical utility of the Multidimensional Objective Pain Assessment Tool (MOPAT) when used over time by critical care nurses to assess acute pain in non-communicative critically ill patients.

METHODS

Twenty-seven patients had pain assessed at two time points (T1 and T2) surrounding a painful event for up to 3 days. Twenty-one ICU nurses participated in pain assessments and completed the Clinical Utility Questionnaire.

RESULTS

Internal consistency reliability coefficient alphas for the MOPAT were .68 at T1 and .72 at T2. Inter-rater agreement during painful procedures or turning was 68% for the behavioral dimension and 80% for the physiologic dimension. Validity was evidenced by decreases (p < .001) in the MOPAT total and behavioral and physiologic dimension scores when comparing T1 and T2. Nurses found the tool clinically useful.

CONCLUSION

The MOPAT can be used in the critical care setting as a helpful tool to assess pain in non-communicative patients. The MOPAT is unique in that the instrument can be used over time and across settings.

Patient Recollection of ICU Procedural Pain and Post ICU Burden: The Memory Study

OBJECTIVE

To assess patients' recollections of in-ICU procedural pain and its impact on post-ICU burden.

DESIGN

Prospective longitudinal study of patients who underwent ICU procedures.

SETTING

Thirty-four ICUs in France and Belgium.

PATIENTS

Two hundred thirty-six patients who had undergone ICU procedures.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Patients were interviewed 3-16 months after hospitalization about: 1) recall of procedural pain intensity and pain distress (on 0-10 numeric rating scale); 2) current pain; that is, having pain in the past week that was not present before hospitalization; and 3) presence of traumatic stress (Impact of Events Scale). For patients who could rate recalled procedural pain intensity (n = 56) and pain distress (n = 43), both were significantly higher than their median (interquartile range) in ICU procedural pain scores (pain intensity: 5 [4-7] vs 3 [2.5-5], p < 0.001; pain distress: 5 [2-6] vs 2 [0-6], p = 0.003, respectively.) Current pain was reported in 14% of patients. When comparing patients with and without current pain, patients with current pain recalled even greater ICU procedural pain intensity and pain distress scores than patients without current pain: pain intensity, 8 (6-8) versus 5 (3.25-7); p = 0.002 and pain distress, 7 (5-8) versus 4 (2-6); p = 0.01, respectively. Patients with current pain also had significantly higher Impact of Events Scale scores than those without current pain (8.5 [3.5-24] vs 2 [0-10]; p < 0.001).

CONCLUSION

Many patients remembered ICU, with far fewer able to rate procedure-associated pain. For those able to do so, recalled pain intensity and pain distress scores were significantly greater than reported in ICU. One in seven patients was having current pain, recalling even higher ICU procedural pain scores and greater traumatic stress when compared with patients without current pain. Studies are needed to assess the impact of ICU procedural pain on post-ICU pain recall, pain status over time, and the relationship between postdischarge pain status and post-ICU burden.

Analgesic efficacy and haemodynamic effects of nefopam in critically ill patients

BACKGROUND

Pain management is challenging in intensive care unit (ICU) patients. The analgesic efficacy, tolerance, and haemodynamic effects of nefopam have never been described in critically ill patients.

METHODS

In consecutive medical-surgical ICU patients who received 20 mg of nefopam i.v. over 30 min, we measured pain, Richmond Agitation Sedation Scale (RASS), respiratory parameters, and adverse drug events at T0 (baseline), T30 (end-of-infusion), T60, and T90 min. Haemodynamic variables were assessed every 15 min from T0 to T60 and T90. Pain was evaluated by the behavioural pain scale (BPS, 3-12) or by the self-reported visual numeric rating scale (NRS, 0-10) according to communication capacity.

RESULTS

Data were analysed for 59 patients. As early as T30, median NRS and BPS decreased significantly from T0 to a minimum level at T60 for NRS [5 (4-7) vs 1 (1-3), P<0.001] and T90 for BPS [5 (5-6) vs 3 (3-4), P<0.001]. No significant changes were detected for RASS, ventilatory frequency, or oxygen saturation. Increased heart rate and decreased mean arterial pressure, defined as a change ≥15% from baseline, were found in 29% and 27% of patients, respectively. For the 18 patients monitored, cardiac output increased by 19 (7-29)% and systemic vascular resistance decreased by 20 (8-28)%, both maximally at T30. Heat sensation, nausea/vomiting, sweating, and mouth dryness were found, respectively, in 6%, 9%, 22%, and 38% of patients.

CONCLUSIONS

A single slow infusion of nefopam is effective in critically ill patients who have moderate pain. The risk of tachycardia and increased cardiac output and also hypotension and decreased systemic vascular resistance should be known to evaluate the benefit/risk ratio of its prescription.

Comparison of two utility instruments, the EQ-5D and the 15D, in the critical care setting

PURPOSE

Reliable measures are required for proper cost-utility analysis after critical care. No gold standard is available, but the EQ-5D health-related quality of life instrument (HRQoL) has been proposed. Our aim was to compare the EQ-5D with another utility measure, the 15D, after critical illness.

METHODS

A total of 929 patients filled in both the EQ-5D and 15D HRQoL instruments 6 and 12 months after treatment at an intensive care or high-dependency unit. The difference in the medians and distributions of the scores of the instruments was tested with Wilcoxon signed-rank test and their association with Spearman rank correlation. Discriminatory power was compared by the ceiling effect and agreement between the instruments regarding the direction of the minimal clinically important change in the HRQoL scores between 6 and 12 months was tested with the McNemar-Bowker test and Cohen's kappa.

RESULTS

The utility scores produced by the instruments and their distributions were different. Agreement between the instruments was only moderate. The 15D appeared more sensitive than the EQ-5D both in terms of discriminatory power and responsiveness to clinically important change.

CONCLUSION

The agreement between the two utility measures was only moderate. The choice of the instrument may have a substantial effect on cost-utility results. Our results suggest that the 15D performs well after critical illness, but further large cohort studies comparing different utility instruments in this patient population are warranted before the gold standard for utility measurement can be announced.

A framework for diagnosing and classifying intensive care unit-acquired weakness

Neuromuscular dysfunction is prevalent in critically ill patients, is associated with worse short-term outcomes, and is a determinant of long-term disability in intensive care unit survivors. Diagnosis is made with the help of clinical, electrophysiological, and morphological observations; however, the lack of a consistent nomenclature remains a barrier to research. We propose a simple framework for diagnosing and classifying neuromuscular disorders acquired in critical illness.

[Pain management]

Analgesia and hypnosis are two separate entities and should result in distinct assessment and management for patients admitted to an intensive care unit (ICU). Those patients are exposed to moderate-severe pain and they are likely to remember pain as one bothersome experience. Any cause of patient discomfort is sought with the priority given to pain and adequate analgesia. Assessing pain must rely upon the use of clinical scoring systems, although these instruments are still underused in ICU. Satisfactory levels of analgesia by continuous infusion of opioids during times without stimulation do not guarantee against pain reactions during procedures (endotracheal suctioning, mobilization, wound care and dressing change, removal of chest tube). The concept of multimodal analgesia should be extended to the ICU since it may reduce the opioids requirements. In order to facilitate systematic pain and sedation assessment and to adjust daily drug dosages accordingly, it appears crucial to promote educational programs and elaboration of protocols/guidelines in ICU. Protocols/guidelines may help caregivers to rationally use sedatives and opioids and possibly reduce mechanical ventilation and ICU length of stay.

A self-report-based study of the incidence and associations of sexual dysfunction in survivors of intensive care treatment

OBJECTIVES

To determine the incidence and associations of sexual dysfunction in survivors of intensive care unit treatment in their first year after hospital discharge using a self-report measure.

DESIGN

A prospective observational study.

SETTING

ICU Follow-up Clinic, The Royal Berkshire Hospital, Reading.

SUBJECTS

One hundred and twenty-seven patients aged 18 years and over who spent 3 days or more in the intensive care unit.

MAIN OUTCOME MEASURES

Demographic data; reported incidence of sexual dysfunction and post-traumatic stress disorder symptomatology; association between reported sexual dysfunction and age, gender, post-traumatic stress disorder symptomatology and length of intensive care unit stay; patient and partner satisfaction with current sex life.

RESULTS

Fifty-two patients (43.6%) reported symptoms of sexual dysfunction. There was a significant association between sexual dysfunction and post-traumatic stress disorder symptomatology (p = 0.019). There was no association between reported sexual dysfunction and gender (p = 0.33), age (p = 0.8) or intensive care unit length of stay (p = 0.41). Forty-five per cent of patients and 40% of partners were not satisfied with their current sex life. No other medical practitioner had sought symptoms of sexual dysfunction during the study period.

CONCLUSIONS

Symptoms of sexual dysfunction are common in patients recovering from critical illness and appear to be significantly associated with the presence of post-traumatic stress disorder symptomatology. The intensive care unit follow-up clinic is a suitable forum for the screening and referral of patients with sexual dysfunction.