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Jayachandran B, Venkatesan K, Tan SBC, Yeo LSH, Venkatacham J, Selvakumar MP, Tan BY. Feasibility of Combining Functional Mobilisation with Resistance and Endurance Training for Mechanically Ventilated Patients in Intensive Care Unit Setting-A Pilot Study. J Clin Med 2024; 13:2412. [PMID: 38673684 PMCID: PMC11051037 DOI: 10.3390/jcm13082412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/06/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Intensive-care-acquired weakness resulting in functional impairment is common in critical care survivors. This study aims to evaluate the feasibility of a combined early functional training with endurance and resistance training and its effect on the functional outcome. Methods: It is a pilot study performed in a 39-bed Medical and Surgical Intensive Care Unit (ICU). Patients who were premorbidly independent and were mechanically ventilated for ≥24 h were recruited to receive functional mobilisation (sit out of bed, ambulation), endurance (bed cycling), and resistance training (selected upper and lower limb muscle training using weights). The primary outcomes were feasibility of training, muscle strength, handgrip strength, quadricep strength, and Functional Status Score-Intensive Care Unit (FSS-ICU) collected at the first assessment in the ICU, at the ICU discharge, and at hospital discharge. Secondary outcomes were functional capacity (6-Minute Walk Distance) and quality of life measures, EQ-5D, at hospital discharge and at 3 months. Results: Out of the 11 patients, 6 (54.54%) patients achieved level 2 functional mobilisation, 2 (18.18%) patients achieved level 2 resistance training, and 1 (9.09%) patient achieved level 2 endurance training. There were no significant differences in the medical research council (MRC) score, quadricep strength, and handgrip strength between the first assessment in the ICU, at the ICU discharge, and at hospital discharge. However, there was a significant difference in FSS_ICU (p < 0.008) from the first assessment in the ICU up to hospital discharge. EQ-5D visual analogue scale also showed a change of 8.5% at 3-month follow-up. 6MWD showed significant difference (p < 0.043) at 3-month follow-up compared to that at hospital discharge. Conclusions: The study found low compliance to resistance and endurance training in patients with mechanical ventilation. However, functional mobilisation in terms of sit out of bed was possible in more than half of the recruited patients.
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Affiliation(s)
| | - Kumaresh Venkatesan
- Anaesthesia Department, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
| | - Sunny Boon Chai Tan
- Rehabilitation Department, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore;
| | - Lynn Soo Hoon Yeo
- Anaesthesia Department, Woodlands Health, 17 Woodlands Dr 17, Singapore 737628, Singapore;
| | - Jonathen Venkatacham
- General Medicine, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore;
| | | | - Bryan Yijia Tan
- Orthopaedic Surgery, Woodlands Health, 17 Woodlands Dr 17, Singapore 737628, Singapore;
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Le Stang V, Latronico N, Dres M, Bertoni M. Critical illness-associated limb and diaphragmatic weakness. Curr Opin Crit Care 2024; 30:121-130. [PMID: 38441088 PMCID: PMC10919276 DOI: 10.1097/mcc.0000000000001135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
PURPOSE OF REVIEW In the current review, we aim to highlight the evolving evidence on the diagnosis, prevention and treatment of critical illness weakness (CIW) and critical illness associated diaphragmatic weakness (CIDW). RECENT FINDINGS In the ICU, several risk factors can lead to CIW and CIDW. Recent evidence suggests that they have different pathophysiological mechanisms and impact on outcomes, although they share common risk factors and may overlap in several patients. Their diagnosis is challenging, because CIW diagnosis is primarily clinical and, therefore, difficult to obtain in the ICU population, and CIDW diagnosis is complex and not easily performed at the bedside. All of these issues lead to underdiagnosis of CIW and CIDW, which significantly increases the risk of complications and the impact on both short and long term outcomes. Moreover, recent studies have explored promising diagnostic techniques that are may be easily implemented in daily clinical practice. In addition, this review summarizes the latest research aimed at improving how to prevent and treat CIW and CIDW. SUMMARY This review aims to clarify some uncertain aspects and provide helpful information on developing monitoring techniques and therapeutic interventions for managing CIW and CIDW.
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Affiliation(s)
- Valentine Le Stang
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique
- AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive -Réanimation (Département 'R3S'), Paris, France
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy
- 'Alessandra BONO' Interdepartmental University Research Center on LOng Term Outcome (LOTO) in Critical Illness Survivors, University of Brescia, Brescia, Italy
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique
- AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive -Réanimation (Département 'R3S'), Paris, France
| | - Michele Bertoni
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia
- Department of Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123 Brescia, Italy
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3
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Panda CK, Karim HMR. Deep Machine Learning Might Aid in Combating Intensive Care Unit-Acquired Weakness. Cureus 2024; 16:e58963. [PMID: 38800279 PMCID: PMC11126887 DOI: 10.7759/cureus.58963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2024] [Indexed: 05/29/2024] Open
Abstract
Secondary muscle weakness in critically ill patients like intensive care unit (ICU)-associated weakness is frequently noted in patients with prolonged mechanical ventilation and ICU stay. It can be a result of critical illness, myopathy, or neuropathy. Although ICU-acquired weakness (ICU-AW) has been known for a while, there is still no effective treatment for it. Therefore, prevention of ICU-AW becomes the utmost priority, and knowing the risk factors is crucial. Nevertheless, the pathophysiology and the attributing causes are complex for ICU-AW, and proper delineation and formulation of a preventive strategy from such vast, multifaceted data are challenging. Artificial intelligence has recently helped healthcare professionals understand and analyze such intricate data through deep machine learning. Hence, using such a strategy also helps in knowing the risk factors and their weight as contributors, applying them in formulating a preventive path for ICU-AW worth trials.
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Affiliation(s)
- Chinmaya K Panda
- Anaesthesiology, Critical Care, and Pain Medicine, All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Habib Md R Karim
- Anesthesiology, Critical Care, and Pain Medicine, All India Institute of Medical Sciences, Guwahati, Guwahati, IND
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4
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Wang L, Long DY. Significant risk factors for intensive care unit-acquired weakness: A processing strategy based on repeated machine learning. World J Clin Cases 2024; 12:1235-1242. [PMID: 38524515 PMCID: PMC10955529 DOI: 10.12998/wjcc.v12.i7.1235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/20/2024] [Accepted: 02/18/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Intensive care unit-acquired weakness (ICU-AW) is a common complication that significantly impacts the patient's recovery process, even leading to adverse outcomes. Currently, there is a lack of effective preventive measures. AIM To identify significant risk factors for ICU-AW through iterative machine learning techniques and offer recommendations for its prevention and treatment. METHODS Patients were categorized into ICU-AW and non-ICU-AW groups on the 14th day post-ICU admission. Relevant data from the initial 14 d of ICU stay, such as age, comorbidities, sedative dosage, vasopressor dosage, duration of mechanical ventilation, length of ICU stay, and rehabilitation therapy, were gathered. The relationships between these variables and ICU-AW were examined. Utilizing iterative machine learning techniques, a multilayer perceptron neural network model was developed, and its predictive performance for ICU-AW was assessed using the receiver operating characteristic curve. RESULTS Within the ICU-AW group, age, duration of mechanical ventilation, lorazepam dosage, adrenaline dosage, and length of ICU stay were significantly higher than in the non-ICU-AW group. Additionally, sepsis, multiple organ dysfunction syndrome, hypoalbuminemia, acute heart failure, respiratory failure, acute kidney injury, anemia, stress-related gastrointestinal bleeding, shock, hypertension, coronary artery disease, malignant tumors, and rehabilitation therapy ratios were significantly higher in the ICU-AW group, demonstrating statistical significance. The most influential factors contributing to ICU-AW were identified as the length of ICU stay (100.0%) and the duration of mechanical ventilation (54.9%). The neural network model predicted ICU-AW with an area under the curve of 0.941, sensitivity of 92.2%, and specificity of 82.7%. CONCLUSION The main factors influencing ICU-AW are the length of ICU stay and the duration of mechanical ventilation. A primary preventive strategy, when feasible, involves minimizing both ICU stay and mechanical ventilation duration.
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Affiliation(s)
- Ling Wang
- Intensive Care Unit, People's Hospital of Qiandongnan Miao and Dong Autonomous Prefecture, Kaili 556000, Guizhou Province, China
| | - Deng-Yan Long
- Intensive Care Unit, People's Hospital of Qiandongnan Miao and Dong Autonomous Prefecture, Kaili 556000, Guizhou Province, China
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5
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Latronico N, Eikermann M, Ely EW, Needham DM. Improving management of ARDS: uniting acute management and long-term recovery. Crit Care 2024; 28:58. [PMID: 38395902 PMCID: PMC10893724 DOI: 10.1186/s13054-024-04810-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/12/2024] [Indexed: 02/25/2024] Open
Abstract
Acute Respiratory Distress Syndrome (ARDS) is an important global health issue with high in-hospital mortality. Importantly, the impact of ARDS extends beyond the acute phase, with increased mortality and disability for months to years after hospitalization. These findings underscore the importance of extended follow-up to assess and address the Post-Intensive Care Syndrome (PICS), characterized by persistent impairments in physical, cognitive, and/or mental health status that impair quality of life over the long-term. Persistent muscle weakness is a common physical problem for ARDS survivors, affecting mobility and activities of daily living. Critical illness and related interventions, including prolonged bed rest and overuse of sedatives and neuromuscular blocking agents during mechanical ventilation, are important risk factors for ICU-acquired weakness. Deep sedation also increases the risk of delirium in the ICU, and long-term cognitive impairment. Corticosteroids also may be used during management of ARDS, particularly in the setting of COVID-19. Corticosteroids can be associated with myopathy and muscle weakness, as well as prolonged delirium that increases the risk of long-term cognitive impairment. The optimal duration and dosage of corticosteroids remain uncertain, and there's limited long-term data on their effects on muscle weakness and cognition in ARDS survivors. In addition to physical and cognitive issues, mental health challenges, such as depression, anxiety, and post-traumatic stress disorder, are common in ARDS survivors. Strategies to address these complications emphasize the need for consistent implementation of the evidence-based ABCDEF bundle, which includes daily management of analgesia in concert with early cessation of sedatives, avoidance of benzodiazepines, daily delirium monitoring and management, early mobilization, and incorporation of family at the bedside. In conclusion, ARDS is a complex global health challenge with consequences extending beyond the acute phase. Understanding the links between critical care management and long-term consequences is vital for developing effective therapeutic strategies and improving the quality of life for ARDS survivors.
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Affiliation(s)
- Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
- Department of Emergency, Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123, Brescia, Italy.
- "Alessandra BONO" Interdepartmental University Research Center on Long-Term Outcome (LOTO) in Critical Illness Survivors, University of Brescia, Brescia, Italy.
| | - M Eikermann
- Department of Anesthesiology, Albert Einstein College of Medicine, Montefiore Medical Center, New York, USA
- Klinik fur Anästhesiologie und Intensivmedizin, Universitaet Duisburg-Essen, Essen, Germany
| | - E W Ely
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - D M Needham
- Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
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Kumar N. Advances in post intensive care unit care: A narrative review. World J Crit Care Med 2023; 12:254-263. [DOI: 10.5492/wjccm.v12.i5.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/29/2023] [Accepted: 11/08/2023] [Indexed: 12/07/2023] Open
Abstract
As the treatment options, modalities and technology have grown, mortality in intensive care unit (ICU) has been on the decline. More and more patients are being discharged to wards and in the care of their loved ones after prolonged treatment at times and sometimes in isolation. These survivors have a lower life expectancy and a poorer quality of life. They can have substantial familial financial implications and an economic impact on the healthcare system in terms of increased and continued utilisation of services, the so-called post intensive care syndrome (PICS). But it is not only the patient who is the sufferer. The mental health of the loved ones and family members may also be affected, which is termed as PICS-family. In this review, we shall be reviewing the definition, epidemiology, clinical features, diagnosis and evaluation, treatment and follow up of PICS. We shall also focus on measures to prevent, rehabilitate and understand the ICU stay from patients’ perspective on how to redesign the ICU, post ICU care needs for a better patient outcome.
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Affiliation(s)
- Nishant Kumar
- Department of Anaesthesiology and Critical Care, Lady Hardinge Medical College and Associated Hospitals, New Delhi 110001, India
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Gaspari R, Spinazzola G, Aceto P, Avolio AW, Delli Compagni M, Postorino S, Michi T, Fachechi DC, Modoni A, Antonelli M. Intensive Care Unit-Acquired Weakness after Liver Transplantation: Analysis of Seven Cases and a Literature Review. J Clin Med 2023; 12:7529. [PMID: 38137598 PMCID: PMC10743957 DOI: 10.3390/jcm12247529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/24/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023] Open
Abstract
Intensive Care Unit (ICU)-Acquired Weakness (ICU-AW) is a generalized muscle weakness that is clinically detected in critical patients and has no plausible etiology other than critical illness. ICU-AW is uncommon in patients undergoing orthotopic liver transplantation (OLT). Our report sheds light on the highest number of ICU-AW cases observed in a single center on OLT patients with early allograft dysfunction. Out of 282 patients who underwent OLT from January 2015 to June 2023, 7 (2.5%) developed generalized muscle weakness in the ICU and underwent neurophysiological investigations. The neurologic examination showed preserved extraocular, flaccid quadriplegia with the absence of deep tendon reflexes in all patients. Neurophysiological studies, including electromyography and nerve conduction studies, showed abnormalities with fibrillation potentials and the rapid recruitment of small polyphasic motor units in the examined muscles, as well as a reduced amplitude of the compound muscle action potential and sensory nerve action potential, with an absence of demyelinating features. Pre-transplant clinical status was critical in all patients. During ICU stay, early allograft dysfunction, acute kidney injury, prolonged mechanical ventilation, sepsis, hyperglycemia, and high blood transfusions were observed in all patients. Two patients were retransplanted. Five patients were alive at 90 days; two patients died. In non-cooperative OLT patients, neurophysiological investigations are essential for the diagnosis of ICU-AW. In this setting, the high number of red blood cell transfusions is a potential risk factor for ICU-AW.
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Affiliation(s)
- Rita Gaspari
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
- Department of Basic Biotechnological Science, Intensive and Peri-Operative Clinics, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Giorgia Spinazzola
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
| | - Paola Aceto
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
- Department of Basic Biotechnological Science, Intensive and Peri-Operative Clinics, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Alfonso Wolfango Avolio
- Department of Translational Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy;
- General Surgery and Liver Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Manuel Delli Compagni
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
| | - Stefania Postorino
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
| | - Teresa Michi
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
| | - Daniele Cosimo Fachechi
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
| | - Anna Modoni
- Department of Geriatric, Neurologic, Orthopedics and Head-Neck Science, Area of Neuroscience, Institute of Neurology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Massimo Antonelli
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (R.G.); (G.S.); (M.D.C.); (S.P.); (T.M.); (D.C.F.); (M.A.)
- Department of Basic Biotechnological Science, Intensive and Peri-Operative Clinics, Catholic University of the Sacred Heart, 00168 Rome, Italy
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Khalil A, Alamri RA, Aljabri GH, Shahat EA, Almughamsi RI, Almeshhen WA. A Cross-Sectional Study of the Impact of ICU-Acquired Weakness: Prevalence, Associations, and Severity. Cureus 2023; 15:e49852. [PMID: 38174172 PMCID: PMC10762283 DOI: 10.7759/cureus.49852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2023] [Indexed: 01/05/2024] Open
Abstract
Background and objective ICU-acquired weakness (ICU-AW) refers to a group of neuromuscular lesions that can develop in the ICU. It leads to decreased physical function, increased in-ICU and in-hospital mortality, and increased healthcare costs. Given its high prevalence and significant impact on patient outcomes, it is essential to have a deeper understanding of ICU-AW. In light of this, this study aimed to ascertain the prevalence, associations, and severity of ICU-AW at a tertiary hospital in the Kingdom of Saudi Arabia (KSA) and to evaluate physician awareness of this condition. Methods A cross-sectional study was conducted in the ICU of Al Madina General Hospital, Medina, KSA, from April 22 to August 22, 2022, involving patients who were 18 years or older and met the inclusion criteria (n=101). The overall muscle strength was assessed daily by using the Medical Research Council (MRC) scale for muscle strength. ICU-AW was identified in patients who experienced a decline in their MRC-Sum Score (MRC-SS) during their ICU stay. Results A total of 101 patients were enrolled in the study. The incidence of ICU-AW was 16.8% (n=17), with 23.5% exhibiting significant weakness and 76.5% having severe weakness. Post hoc comparisons showed that females had a higher incidence of ICU-AW. Fisher's exact test revealed a statistically significant relationship between ICU-AW and the longer duration of ICU stay (p=0.001), use of mechanical ventilation (p=0.034), and low hemoglobin levels (p=0.037). Conclusions ICU-AW was observed in 16.8% (n=17) of patients in our cohort, highlighting the significance of this condition. The study revealed a noteworthy correlation between ICU-AW and female sex, extended ICU stays, mechanical ventilation, and anemia.
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Affiliation(s)
- Anas Khalil
- Internal Medicine, Taibah University, Medina, SAU
| | - Ruba A Alamri
- Medicine and Surgery, Taibah University, Medina, SAU
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Elkalawy H, Sekhar P, Abosena W. Early detection and assessment of intensive care unit-acquired weakness: a comprehensive review. Acute Crit Care 2023; 38:409-424. [PMID: 38052508 DOI: 10.4266/acc.2023.00703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 10/17/2023] [Indexed: 12/07/2023] Open
Abstract
Intensive care unit-acquired weakness (ICU-AW) is a serious complication in critically ill patients. Therefore, timely and accurate diagnosis and monitoring of ICU-AW are crucial for effectively preventing its associated morbidity and mortality. This article provides a comprehensive review of ICU-AW, focusing on the different methods used for its diagnosis and monitoring. Additionally, it highlights the role of bedside ultrasound in muscle assessment and early detection of ICU-AW. Furthermore, the article explores potential strategies for preventing ICU-AW. Healthcare providers who manage critically ill patients utilize diagnostic approaches such as physical exams, imaging, and assessment tools to identify ICU-AW. However, each method has its own limitations. The diagnosis of ICU-AW needs improvement due to the lack of a consensus on the appropriate approach for its detection. Nevertheless, bedside ultrasound has proven to be the most reliable and cost-effective tool for muscle assessment in the ICU. Combining the Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation (APACHE) II score assessment, and ultrasound can be a convenient approach for the early detection of ICU-AW. This approach can facilitate timely intervention and prevent catastrophic consequences. However, further studies are needed to strengthen the evidence.
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Affiliation(s)
- Hanan Elkalawy
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - Pavan Sekhar
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA, USA
| | - Wael Abosena
- Department of Surgery, Faculty of Medicine, Tanta University, Gharbeya, Egypt
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10
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Puri S, Magoon R, Bandyopadhyay A. Comment on: "Predictive factors and clinical impact of ICU-acquired weakness on functional disability in mechanically ventilated patients with COVID-19″. Heart Lung 2023; 62:280. [PMID: 37085437 PMCID: PMC10083201 DOI: 10.1016/j.hrtlng.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 04/06/2023] [Accepted: 04/07/2023] [Indexed: 04/23/2023]
Affiliation(s)
- Sunaakshi Puri
- Senior Resident, Department of Anesthesia, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Rohan Magoon
- Assistant Professor, Department of Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi 110001, India
| | - Anjishnujit Bandyopadhyay
- Assistant Professor, Department of Anaesthesiology, Pain Medicine and Critical Care, Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi 110029, India.
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Stamatiou R, Vasilaki A, Tzini D, Tsolaki V, Zacharouli K, Ioannou M, Fotakopoulos G, Sgantzos M, Makris D. Critical-Illness: Combined Effects of Colistin and Vasoactive Drugs: A Pilot Study. Antibiotics (Basel) 2023; 12:1057. [PMID: 37370376 DOI: 10.3390/antibiotics12061057] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Colistin is often used as a last resort for treating multidrug-resistant infections, particularly in critically ill patients in intensive care units. Nonetheless, its side effects, including myopathy, require careful monitoring. Vasoconstrictive drugs are also used in intensive care to increase blood pressure and improve blood flow to vital organs, which can be compromised in critically ill patients. The exact mechanism of colistin-induced muscle toxicity is of significant interest due to its potential intensive-care clinical implications. Colistin alone or in combination with vasoconstrictive agents was administrated in non-septic and LPS-induced septic animals for 10 days. Histopathological evaluation of the gastrocnemius muscle and dot-blot protein tissue analysis were performed. Increased intramuscular area, de-organization of the muscle fibers and signs of myopathy were observed in colistin-treated animals. This effect was ameliorated in the presence of vasoconstrictive drugs. Administration of colistin to septic animals resulted in a decrease of AMPK and cyclin-D1 levels, while it had no effect on caspase 3 levels. Vasoconstrictive drugs' administration reversed the effects of colistin on AMPK and cyclin D1 levels. Colistin's effects on muscle depend on septic state and vasoconstriction presence, highlighting the need to consider these factors when administering it in critically ill patients.
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Affiliation(s)
- Rodopi Stamatiou
- Physiology Laboratory, Faculty of Medicine, University of Thessaly, Biopolis, 41500 Larissa, Greece
| | - Anna Vasilaki
- Laboratory of Pharmacology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, 41221 Larissa, Greece
| | - Dimitra Tzini
- Laboratory of Pharmacology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, 41221 Larissa, Greece
| | - Vasiliki Tsolaki
- Intensive Care Unit, Faculty of Medicine, University of Thessaly, Biopolis, 41500 Larissa, Greece
| | - Konstantina Zacharouli
- Pathology Department, Faculty of Medicine, University of Thessaly, Biopolis, 41500 Larissa, Greece
| | - Maria Ioannou
- Pathology Department, Faculty of Medicine, University of Thessaly, Biopolis, 41500 Larissa, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, University Hospital of Larissa, 41500 Larisa, Greece
| | - Markos Sgantzos
- Anatomy Department, Faculty of Medicine, University of Thessaly, Biopolis, 41500 Larissa, Greece
| | - Demosthenes Makris
- Intensive Care Unit, Faculty of Medicine, University of Thessaly, Biopolis, 41500 Larissa, Greece
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Zaragoza-García I, Arias-Rivera S, Frade-Mera MJ, Martí JD, Gallart E, San José-Arribas A, Velasco-Sanz TR, Blazquez-Martínez E, Raurell-Torredà M. Enteral nutrition management in critically ill adult patients and its relationship with intensive care unit-acquired muscle weakness: A national cohort study. PLoS One 2023; 18:e0286598. [PMID: 37285356 DOI: 10.1371/journal.pone.0286598] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 05/19/2023] [Indexed: 06/09/2023] Open
Abstract
OBJECTIVE To assess the incidence and determinants of ICU-acquired muscle weakness (ICUAW) in adult patients with enteral nutrition (EN) during the first 7 days in the ICU and mechanical ventilation for at least 48 hours. METHODS A prospective, nationwide, multicentre cohort study in a national ICU network of 80 ICUs. ICU patients receiving invasive mechanical ventilation for at least 48 hours and EN the first 7 days of their ICU stay were included. The primary outcome was incidence of ICUAW. The secondary outcome was analysed, during days 3-7 of ICU stay, the relationship between demographic and clinical data to contribute to the onset of ICUAW, identify whether energy and protein intake can contribute independently to the onset of ICUAW and degree of compliance guidelines for EN. RESULTS 319 patients were studied from 69 ICUs in our country. The incidence of ICUAW was 153/222 (68.9%; 95% CI [62.5%-74.7%]). Patients without ICUAW showed higher levels of active mobility (p = 0.018). The logistic regression analysis showed no effect on energy or protein intake on the onset of ICUAW. Overfeeding was observed on a significant proportion of patient-days, while more overfeeding (as per US guidelines) was found among patients with obesity than those without (42.9% vs 12.5%; p<0.001). Protein intake was deficient (as per US/European guidelines) during ICU days 3-7. CONCLUSIONS The incidence of ICUAW was high in this patient cohort. Early mobility was associated with a lower incidence of ICUAW. Significant overfeeding and deficient protein intake were observed. However, energy and protein intake alone were insufficient to explain ICUAW onset. RELEVANCE TO CLINICAL PRACTICE Low mobility, high incidence of ICUAW and low protein intake suggest the need to train, update and involve ICU professionals in nutritional care and the need for early mobilization of ICU patients.
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Affiliation(s)
- Ignacio Zaragoza-García
- Department of Nursing, Faculty of Nursing, Physiotherapy and Podology, University Complutense of Madrid, Madrid, Spain
- Invecuid, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Susana Arias-Rivera
- University Hospital of Getafe, CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Getafe, Spain
| | - María Jesús Frade-Mera
- Department of Nursing, Faculty of Nursing, Physiotherapy and Podology, University Complutense of Madrid, Madrid, Spain
- Department of Critical Care, 12 Octubre University Hospital, Madrid, Spain
| | | | - Elisabet Gallart
- Department of Critical Care, Vall Hebron University Hospital, Barcelona, Spain
| | - Alicia San José-Arribas
- Escola Universitaria d'Infermeria Sant Pau, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Tamara Raquel Velasco-Sanz
- Department of Nursing, Faculty of Nursing, Physiotherapy and Podology, University Complutense of Madrid, Madrid, Spain
- Department of Critical Care, San Carlos University Hospital, Madrid, Spain
| | | | - Marta Raurell-Torredà
- Department d'Infermeria Fonamental i medicoquirúrgica, Facultat d'Infermeria, Universitat de Barcelona, Barcelona, Spain
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Watanabe S, Hirasawa J, Naito Y, Mizutani M, Uemura A, Nishimura S, Morita Y, Iida Y. Association between the early mobilization of mechanically ventilated patients and independence in activities of daily living at hospital discharge. Sci Rep 2023; 13:4265. [PMID: 36918635 PMCID: PMC10015081 DOI: 10.1038/s41598-023-31459-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 03/13/2023] [Indexed: 03/16/2023] Open
Abstract
Physical dysfunction after discharge from the intensive care unit (ICU) is recognized as a common complication among ICU patients. Early mobilization (EM), defined as the ability to sit on the edge of the bed within 5 days, may help improve physical dysfunction. However, the barriers to, and achievement of, EM and their impact on physical dysfunction have not been fully investigated. This study aimed to investigate the achievement of EM and barriers to it and their impact on patient outcomes in mechanically ventilated ICU patients. We conducted this multicenter retrospective cohort study by collecting data from six ICUs in Japan. Consecutive patients who were admitted to the ICU between April 2019 and March 2020, were aged ≥ 18 years, and received mechanical ventilation for > 48 h were eligible. The primary outcome was the rate of independent activities of daily living (ADL), defined as a score ≥ 70 on the Barthel index at hospital discharge. Daily changes in barriers of mobilization, including consciousness, respiratory, circulatory, medical staff factors, and device factors (catheter, drain, and dialysis), along with the clinical outcomes were investigated. The association among barriers, mobilization, and Barthel index ≥ 70 was analyzed using multivariable logistic regression analysis. During the study period, 206 patients were enrolled. EM was achieved in 116 patients (68%) on the fifth ICU day. The primary outcome revealed that achieving EM was associated with a Barthel index ≥ 70 at hospital discharge [adjusted odds ratio (AOR), 3.44; 95% confidence interval (CI), 1.70-6.96]. Device factors (AOR, 0.31; 95% CI, 0.13-0.75, respectively) were significantly associated with EM achievement. EM was associated with independent ADL at hospital discharge. Time to first mobilization and barriers to achieving mobilization can be important parameters for achieving ADL independence at discharge. Further research is required to determine the most common barriers so that they can be identified and removed.
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Affiliation(s)
- Shinichi Watanabe
- Department of Rehabilitation Medicine, National Hospital Organization, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-ku, Nagoya, Aichi, 460-0001, Japan. .,Department of Physical Therapy, Faculty of Rehabilitation, Gifu University of Health Science, Gifu, Gifu, Japan.
| | - Jun Hirasawa
- Department of Rehabilitation Medicine, Tosei General Hospital, Seto, Aichi, Japan
| | - Yuji Naito
- Department of Rehabilitation Medicine, National Hospital Organization, Shizuoka Medical Center, Nagasawa, Shimizu, Suntougun, Shizuoka, Japan
| | - Motoki Mizutani
- Department of Rehabilitation Medicine, Ichinomiyanishi Hospital, Kaimeitaira, Itinomiya, Aichi, Japan
| | - Akihiro Uemura
- Department of Rehabilitation, Toyohashi Municipal Hospital, Hachikennishi, Aotake, Toyohashi, Aichi, Japan
| | - Shogo Nishimura
- Department of Rehabilitation Medicine, Kainan Hospital, Namihonden, Maegasu, Yatomi, Aichi, Japan
| | - Yasunari Morita
- Department of Emergency Medicine, National Hospital Organization, Nagoya Medical Center, Sannomaru, Nakaku, Nagoya, Aichi, Japan
| | - Yuki Iida
- Department of Physical Therapy, School of Health Sciences, Toyohashi Sozo University, 20-1 Matushita, Ushikawa-cho, Toyohashi, Aichi, 440-8511, Japan.
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14
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Ribeiro Carvalho CR, Lamas CA, Chate RC, Salge JM, Sawamura MVY, de Albuquerque ALP, Toufen Junior C, Lima DM, Garcia ML, Scudeller PG, Nomura CH, Gutierrez MA, Baldi BG. Long-term respiratory follow-up of ICU hospitalized COVID-19 patients: Prospective cohort study. PLoS One 2023; 18:e0280567. [PMID: 36662879 PMCID: PMC9858876 DOI: 10.1371/journal.pone.0280567] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/02/2023] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Coronavirus disease (COVID-19) survivors exhibit multisystemic alterations after hospitalization. Little is known about long-term imaging and pulmonary function of hospitalized patients intensive care unit (ICU) who survive COVID-19. We aimed to investigate long-term consequences of COVID-19 on the respiratory system of patients discharged from hospital ICU and identify risk factors associated with chest computed tomography (CT) lesion severity. METHODS A prospective cohort study of COVID-19 patients admitted to a tertiary hospital ICU in Brazil (March-August/2020), and followed-up six-twelve months after hospital admission. Initial assessment included: modified Medical Research Council dyspnea scale, SpO2 evaluation, forced vital capacity, and chest X-Ray. Patients with alterations in at least one of these examinations were eligible for CT and pulmonary function tests (PFTs) approximately 16 months after hospital admission. Primary outcome: CT lesion severity (fibrotic-like or non-fibrotic-like). Baseline clinical variables were used to build a machine learning model (ML) to predict the severity of CT lesion. RESULTS In total, 326 patients (72%) were eligible for CT and PFTs. COVID-19 CT lesions were identified in 81.8% of patients, and half of them showed mild restrictive lung impairment and impaired lung diffusion capacity. Patients with COVID-19 CT findings were stratified into two categories of lesion severity: non-fibrotic-like (50.8%-ground-glass opacities/reticulations) and fibrotic-like (49.2%-traction bronchiectasis/architectural distortion). No association between CT feature severity and altered lung diffusion or functional restrictive/obstructive patterns was found. The ML detected that male sex, ICU and invasive mechanic ventilation (IMV) period, tracheostomy and vasoactive drug need during hospitalization were predictors of CT lesion severity(sensitivity,0.78±0.02;specificity,0.79±0.01;F1-score,0.78±0.02;positive predictive rate,0.78±0.02; accuracy,0.78±0.02; and area under the curve,0.83±0.01). CONCLUSION ICU hospitalization due to COVID-19 led to respiratory system alterations six-twelve months after hospital admission. Male sex and critical disease acute phase, characterized by a longer ICU and IMV period, and need for tracheostomy and vasoactive drugs, were risk factors for severe CT lesions six-twelve months after hospital admission.
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Affiliation(s)
- Carlos Roberto Ribeiro Carvalho
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), Sao Paulo, SP, Brazil
| | - Celina Almeida Lamas
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), Sao Paulo, SP, Brazil
| | - Rodrigo Caruso Chate
- Radiology Institute (InRad), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), Sao Paulo, SP, Brazil
| | - João Marcos Salge
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), Sao Paulo, SP, Brazil
| | - Marcio Valente Yamada Sawamura
- Radiology Institute (InRad), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), Sao Paulo, SP, Brazil
| | - André L. P. de Albuquerque
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), Sao Paulo, SP, Brazil
| | - Carlos Toufen Junior
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), Sao Paulo, SP, Brazil
| | - Daniel Mario Lima
- Informatics Division, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), Sao Paulo, SP, Brazil
| | - Michelle Louvaes Garcia
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), Sao Paulo, SP, Brazil
| | - Paula Gobi Scudeller
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), Sao Paulo, SP, Brazil
| | - Cesar Higa Nomura
- Radiology Institute (InRad), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), Sao Paulo, SP, Brazil
| | - Marco Antonio Gutierrez
- Informatics Division, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), Sao Paulo, SP, Brazil
| | - Bruno Guedes Baldi
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), Sao Paulo, SP, Brazil
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15
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Yang Z, Wang X, Chang G, Cao Q, Wang F, Peng Z, Fan Y. Development and validation of an intensive care unit acquired weakness prediction model: A cohort study. Front Med (Lausanne) 2023; 10:1122936. [PMID: 36910489 PMCID: PMC9993479 DOI: 10.3389/fmed.2023.1122936] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/06/2023] [Indexed: 02/24/2023] Open
Abstract
Background At present, intensive care unit acquired weakness (ICU-AW) has become an important health care issue. The aim of this study was to develop and validate an ICU-AW prediction model for adult patients in intensive care unit (ICU) to provide a practical tool for early clinical diagnosis. Methods An observational cohort study was conducted including 400 adult patients admitted from September 2021 to June 2022 at an ICU with four ward at a medical university affiliated hospital in China. The Medical Research Council (MRC) scale was used to assess bedside muscle strength in ICU patients as a diagnostic basis for ICUAW. Patients were divided into the ICU-AW group and the no ICU-AW group and the clinical data of the two groups were statistically analyzed. A risk prediction model was then developed using binary logistic regression. Sensitivity, specificity, and the area under the curve (AUC) were used to evaluate the predictive ability of the model. The Hosmer-Lemeshow test was used to assess the model fit. The bootstrap method was used for internal verification of the model. In addition, the data of 120 patients in the validation group were selected for external validation of the model. Results The prediction model contained five risk factors: gender (OR: 4.31, 95% CI: 1.682-11.042), shock (OR: 3.473, 95% CI: 1.191-10.122), mechanical ventilation time (OR: 1.592, 95% CI: 1.317-1.925), length of ICU stay (OR: 1.085, 95% CI: 1.018-1.156) and age (OR: 1.075, 95% CI: 1.036-1.115). The AUC of this model was 0.904 (95% CI: 0.847-0.961), with sensitivity of 87.5%, specificity of 85.8%, and Youden index of 0.733. The AUC of the model after resampling is 0.889. The model verification results showed that the sensitivity, specificity and accuracy were 71.4, 92.9, and 92.9%, respectively. Conclusion An accurate, and readily implementable, risk prediction model for ICU-AW has been developed. This model uses readily obtained variables to predict patient ICU-AW risk. This model provides a tool for early clinical screening for ICU-AW.
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Affiliation(s)
- Zi Yang
- Clinical Nursing Teaching Department, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.,School of Nursing, Harbin Medical University, Harbin, China
| | - Xiaohui Wang
- Department of Nursing, Shenzhen Qianhai Taikang Hospital, Shenzhen, China
| | - Guangming Chang
- Office of Medical Ethics Committee, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qiuli Cao
- Surgical Laboratory, Department of Medical Education, The First Affiliated Hospital of Jiamusi University, Jiamusi, China
| | - Faying Wang
- Clinical Nursing Teaching Department, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.,School of Nursing, Harbin Medical University, Harbin, China
| | - Zeyu Peng
- Clinical Nursing Teaching Department, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.,School of Nursing, Harbin Medical University, Harbin, China
| | - Yuying Fan
- Clinical Nursing Teaching Department, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.,School of Nursing, Harbin Medical University, Harbin, China
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16
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Borges LF, Fraga Righetti R, de Souza Francisco D, Pereira Yamaguti W, Barros CFD. Hemodynamic impact of early mobilization in critical patients receiving vasoactive drugs: A prospective cohort study. PLoS One 2022; 17:e0279269. [PMID: 36538515 PMCID: PMC9767358 DOI: 10.1371/journal.pone.0279269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 12/03/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Vasoactive drugs are one of the most common patient-related barriers to early mobilization. Little is known about the hemodynamic effects of early mobilization on patients receiving vasoactive drugs. This study aims to observe and describe the impact of mobilization on the vital signs of critical patients receiving vasoactive drugs as well as the occurrence of adverse events. METHODS This is a cohort study performed in an Intensive Care Unit with patients receiving vasoactive drugs. All patients, either mobilized or non-mobilized, had their clinical data such as vital signs [heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and oxygen saturation], type and dosage of the vasoactive drug, and respiratory support collected at rest. For mobilized patients, the vital signs were also collected after mobilization, and so was the highest level of mobility achieved and the occurrence of adverse events. The criteria involved in the decision of mobilizing the patients were registered. RESULTS 53 patients were included in this study and 222 physiotherapy sessions were monitored. In most of the sessions (n = 150, 67.6%), patients were mobilized despite the use of vasoactive drugs. There was a statistically significant increase in heart rate and respiratory rate after mobilization when compared to rest (p<0.05). Only two (1.3%) out of 150 mobilizations presented an adverse event. Most of the time, non-mobilizations were justified by the existence of a clinical contraindication (n = 61, 84.7%). CONCLUSIONS The alterations observed in the vital signs of mobilized patients may have reflected physiological adjustments of patients' cardiovascular and respiratory systems to the increase in physical demand imposed by the early mobilization. The adverse events were rare, not serious, and reversed through actions such as a minimal increase of the vasoactive drug dosage.
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17
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Zhou J, Zhang C, Zhou JD, Zhang CK. Effect of early progressive mobilization on intensive care unit-acquired weakness in mechanically ventilated patients: An observational study. Medicine (Baltimore) 2022; 101:e31528. [PMID: 36343079 PMCID: PMC9646566 DOI: 10.1097/md.0000000000031528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Early progressive mobilization is usually considered as an effective method for intensive care unit-acquired weakness (ICU-AW), but the controversies on this topic remain debatable, especially in initiation time, safety profile, and other implementation details. So, more studies should be performed to solve these disputes. A set of critically ill patients underwent mechanical ventilation in intensive care unit (ICU) of our hospital from March 2018 to September 2020 were included as study object. Patients received early progressive mobilization were included into the intervention group (n = 160), and another patients matched with the intervention group by gender, age, and APACHE II score, and these patients received routine intervention were included into the control group (n = 160). Then, indexes involving muscle strength, Barthel index, functional independence, incidence rates of ICU-AW and other complications were comparatively analyzed between the 2 groups. The Medical Research Council score and Barthel index score in the intervention group were significantly higher than those in the control group (all P < .05). The percentages of patients who were able to complete taking a shower, wearing clothes, eating, grooming, moving from bed to chair and using the toilet by alone in the intervention group were significantly higher than those in the control group (69.38% vs 49.38%, 73.13% vs 51.88%, 81.25% vs 55.63%, 74.38% vs 48.75%, 82.50% vs 65.63%, 78.13% vs 63.13%, respectively, all P < .05). The incidence rate of ICU-AW and overall incidence rate of complications in the intervention group were significantly lower than those in the control group (6.88% vs 28.13% and 23.13% vs 48.13%, both P < .05). Early progressive mobilization can effectively increase muscle strength and daily basic motion ability, improve functional status, and decrease risk of ICU-AW in critically ill patients underwent mechanical ventilation, and it has an attractive application value in clinic.
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Affiliation(s)
- Jing Zhou
- Intensive Care Unit, The Fenghua People’s Hospital, Ningbo City, Zhejiang Province, China
| | - Chao Zhang
- Intensive Care Unit, The Fenghua People’s Hospital, Ningbo City, Zhejiang Province, China
| | - Ji-dong Zhou
- Intensive Care Unit, The Fenghua People’s Hospital, Ningbo City, Zhejiang Province, China
- * Correspondence: Ji-dong Zhou, the Fenghua People’s Hospital, Ningbo City 315500, Zhejiang Province, China (e-mail: )
| | - Cheng-kai Zhang
- Intensive Care Unit, The Fenghua People’s Hospital, Ningbo City, Zhejiang Province, China
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18
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Gonzalez A, Abrigo J, Achiardi O, Simon F, Cabello-Verrugio C. Intensive care unit-acquired weakness: From molecular mechanisms to its impact in COVID-2019. Eur J Transl Myol 2022; 32. [PMID: 36036350 PMCID: PMC9580540 DOI: 10.4081/ejtm.2022.10511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/08/2022] [Indexed: 01/08/2023] Open
Abstract
Intensive Care Unit-Acquired Weakness (ICU-AW) is a generalized and symmetric neuromuscular dysfunction associated with critical illness and its treatments. Its incidence is approximately 80% in intensive care unit patients, and it manifests as critical illness polyneuropathy, critical illness myopathy, and muscle atrophy. Intensive care unit patients can lose an elevated percentage of their muscle mass in the first days after admission, producing short- and long-term sequelae that affect patients’ quality of life, physical health, and mental health. In 2019, the world was faced with coronavirus disease 2019 (COVID-19), caused by the acute respiratory syndrome coronavirus 2. COVID-19 produces severe respiratory disorders, such as acute respiratory distress syndrome, which increases the risk of developing ICU-AW. COVID-19 patients treated in intensive care units have shown early diffuse and symmetrical muscle weakness, polyneuropathy, and myalgia, coinciding with the clinical presentation of ICU-AW. Besides, these patients require prolonged intensive care unit stays, invasive mechanical ventilation, and intensive care unit pharmacological therapy, which are risk factors for ICU-AW. Thus, the purposes of this review are to discuss the features of ICU-AW and its effects on skeletal muscle. Further, we will describe the mechanisms involved in the probable development of ICU-AW in severe COVID-19 patients.
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Selepressin in Septic Shock. Shock 2022; 57:172-179. [PMID: 35759300 DOI: 10.1097/shk.0000000000001932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Sepsis and septic shock usually show a high mortality rate and frequently need of intensive care unit admissions. After fluid resuscitation, norepinephrine (NE) is the first-choice vasopressor in septic shock patients. However, high-NE doses are associated with increased rates of adverse effects and mortality. In this perspective, many authors have proposed the administration of non-adrenergic vasopressors (NAV). Selepressin is a selective vasopressin type 1A (V1A) receptor agonist and may be a valid option in this field, because it can decrease NE requirements and also limit the deleterious effects induced by high doses of catecholamines. Only few clinical data actually support selepressin administration in this setting. Here, we review the current literature on this topic analyzing some pathophysiological aspects, the rationale about the use of NAV, the possible use of selepressin differentiating animal, and human studies. Various issues remain unresolved and future trials should be focused on early interventions based on a multimodal activation of the vasopressive pathways using both alpha and V1A receptors pathways.
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Schmidt D, Piva TC, Glaeser SS, Piekala DM, Berto PP, Friedman G, Sbruzzi G. Intensive Care Unit-Acquired Weakness in Patients With COVID-19: Occurrence and Associated Factors. Phys Ther 2022; 102:6540311. [PMID: 35233607 PMCID: PMC8903454 DOI: 10.1093/ptj/pzac028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 12/14/2021] [Accepted: 01/08/2022] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The primary objective of this study was to identify the occurrence and factors associated with intensive care unit (ICU)-acquired weakness (ICUAW) in patients with COVID-19. Secondarily, we monitored the evolution of muscle strength and mobility among individuals with ICUAW and those without ICUAW and the association of these variables with length of stay, mechanical ventilation (MV), and other clinical variables. METHODS In this prospective observational study, individuals admitted to the ICU for >72 hours with COVID-19 were evaluated for muscle strength and mobility at 3 times: when being weaned from ventilatory support, discharged from the ICU, and discharged from the hospital. Risk factors for ICUAW were monitored. RESULTS The occurrences of ICUAW at the 3 times evaluated among the 75 patients included were 52%, 38%, and 13%. The length of the ICU stay (29.5 [IQR = 16.3-42.5] vs 11 [IQR = 6.5-16] days), the length of the hospital stay (43.5 [IQR = 22.8-55.3] vs 16 [IQR = 12.5-24] days), and time on MV (25.5 [IQR = 13.8-41.3] vs 10 [IQR = 5-22.5] days) were greater in patients with ICUAW. Muscle strength and mobility were lower at all times assessed in patients with ICUAW. Bed rest time for all patients (relative risk = 1.14; 95% CI = 1.02 to 1.28) and use of corticosteroids (relative risk = 1.01; 95% CI = 1.00 to 1.03) for those who required MV were factors independently associated with ICUAW. Muscle strength was found to have a positive correlation with mobility and a negative correlation with lengths of stay in the ICU and hospital and time on MV. CONCLUSION The occurrence of ICUAW was high on patients' awakening in the ICU but decreased throughout hospitalization; however, strength and mobility remained compromised at hospital discharge. Bed rest time and use of corticosteroids (for those who needed MV) were factors independently associated with ICUAW in patients with COVID-19. IMPACT Patients who had COVID-19 and developed ICUAW had longer periods of ICU stay, hospital stay, and MV. Bed rest time and use of corticosteroids (for those who required MV) were factors independently associated with ICUAW.
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Affiliation(s)
- Débora Schmidt
- Serviço de Fisioterapia, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brasil,Postgraduate Program in Human Movement Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brasil,Address all correspondence to
| | - Taila Cristina Piva
- Serviço de Fisioterapia, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brasil
| | - Sheila Suzana Glaeser
- Serviço de Fisioterapia, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brasil
| | - Daniele Martins Piekala
- Serviço de Fisioterapia, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brasil
| | | | - Gilberto Friedman
- Serviço de Medicina Intensiva, HCPA, Porto Alegre, Rio Grande do Sul, Brasil
| | - Graciele Sbruzzi
- Serviço de Fisioterapia, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Rio Grande do Sul, Brasil,Postgraduate Program in Human Movement Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brasil
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21
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Vrettou CS, Mantziou V, Vassiliou AG, Orfanos SE, Kotanidou A, Dimopoulou I. Post-Intensive Care Syndrome in Survivors from Critical Illness including COVID-19 Patients: A Narrative Review. Life (Basel) 2022; 12:life12010107. [PMID: 35054500 PMCID: PMC8778667 DOI: 10.3390/life12010107] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 12/21/2022] Open
Abstract
Current achievements in medical science and technological advancements in intensive care medicine have allowed better support of critically ill patients in intensive care units (ICUs) and have increased survival probability. Post-intensive care syndrome (PICS) is a relatively new term introduced almost 10 years ago, defined as "new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization". A significant percentage of critically ill patients suffer from PICS for a prolonged period of time, with physical problems being the most common. The exact prevalence of PICS is unknown, and many risk factors have been described well. Coronavirus disease 2019 (COVID-19) survivors seem to be at especially high risk for developing PICS. The families of ICU survivors can also be affected as a response to the stress suffered during the critical illness of their kin. This separate entity is described as PICS family (PICS-F). A multidisciplinary approach is warranted for the treatment of PICS, involving healthcare professionals, clinicians, and scientists from different areas. Improving outcomes is both challenging and imperative for the critical care community. The review of the relevant literature and the study of the physical, cognitive, and mental sequelae could lead to the prevention and timely management of PICS and the subsequent improvement of the quality of life for ICU survivors.
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22
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Tortuyaux R, Davion JB, Jourdain M. Intensive care unit-acquired weakness: Questions the clinician should ask. Rev Neurol (Paris) 2022; 178:84-92. [PMID: 34998522 DOI: 10.1016/j.neurol.2021.12.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 12/29/2022]
Abstract
Intensive care unit (ICU)-acquired weakness (ICU-AW) is defined as clinically detected weakness in critically ill patients in whom there is no plausible etiology other than critical illness. Using electrophysiological methods, patients with ICU-AW are classified in three subcategories: critical illness polyneuropathy, critical illness myopathy and critical illness neuromyopathy. ICU-AW is a frequent complication occurring in critical ill patients. Risk factors include illness severity and organ failure, age, hyperglycemia, parenteral nutrition, drugs and immobility. Due to short- and long-term complications, ICU-AW results in longer hospital stay and increased mortality. Its management is essentially preventive avoiding modifiable risk factors, especially duration of sedation and immobilization that should be as short as possible. Pharmacological approaches have been studied but none have proven efficacy. In the present review, we propose practical questions that the clinician should ask in case of acquired weakness during ICU stay: when to suspect ICU-AW, what risk factors should be identified, how to diagnose ICU-AW, what is the prognosis and how can recovery be improved?
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Affiliation(s)
- R Tortuyaux
- CHU de Lille, médecine intensive-réanimation, 59000 Lille, France; CHU de Lille, department of clinical neurophysiology, 59000 Lille, France.
| | - J-B Davion
- CHU de Lille, centre de référence des maladies neuromusculaires, 59000 Lille, France
| | - M Jourdain
- CHU de Lille, médecine intensive-réanimation, 59000 Lille, France; Université Lille, Inserm U1190, 59000 Lille, France
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Yuan G, Zhang J, Mou Z, Luo J, Xie Y. Acute reduction of erector spinae muscle cross-sectional area is associated with ICU-AW and worse prognosis in patients with mechanical ventilation in the ICU: A prospective observational study. Medicine (Baltimore) 2021; 100:e27806. [PMID: 34964749 PMCID: PMC8615325 DOI: 10.1097/md.0000000000027806] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/27/2021] [Accepted: 10/27/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND To investigate the values of erector spinae muscle cross-sectional area (ESMcsa) loss for diagnosing intensive care unit-acquired weakness (ICU-AW) and predicting the 60-day survival status in patients with mechanical ventilation. METHODS Patients who were admitted into the intensive care unit (ICU) and received invasive mechanical ventilation therapy from June 2018 to June 2020 were selected. And they were divided into an ICU-AW group and a non-ICU-AW group, which were compared based on the ESMcsa and The British Medical Research Council muscle strength score (MRC-score) on the 1st and 7th day of ICU admission. The receiver operating characteristic curve was employed to measure the values of the ESMcsa Loss and ESMcsa Loss Ratio on the 7th day in order to diagnose ICU-AW in patients with mechanical ventilation. The survival curves of the patients were plotted to analyze the ESMcsa Loss Ratio values for predicting the 60-day survival status. RESULTS A total of 104 patients were enrolled, they were divided into the ICU-AW group (n = 56) and the non-ICU-AW group (n = 48). The mechanical ventilation time, ICU stay time, and hospital stay time of the ICU-AW group were all significantly higher than those of the non-ICU-AW group. On the 1st day, no significant difference in the ESMcsa or MRC-score between the 2 groups of patients was observed. On the 7th day, the ESMcsa and MRC-score of the ICU-AW group were significantly lower than those of the non-ICU-AW group. The ESMcsa Loss and ESMcsa Loss Ratio were both significantly negatively correlated with the MRC-score. The ESMcsa Loss and ESMcsa Loss Ratio on the 7th day were both valuable for the prediction of ICU-AW in patients with mechanical ventilation (areas under the receiver operating characteristic curve = 0.904, 0.835, and 0.889, P < .001). The survival rate of the patients in the high- and low-ESMcsa Loss Ratio groups were 60.0% and 80.0% (P < .05). CONCLUSIONS As suggested by the ESMcsa Loss Ratios of the patients with mechanical ventilation on the 7th day of ICU admission, it offers a desirable objective indicator for the diagnosis of ICU-AW, and provides certain values for predicting the 60-day survival status of patients with mechanical ventilation in the ICU.
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Affiliation(s)
- Gang Yuan
- Department of Radiology, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Jie Zhang
- Department of Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Zhifang Mou
- Department of Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Jiye Luo
- Department of Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Yongpeng Xie
- Department of Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, The First People's Hospital of Lianyungang, Lianyungang, China
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Liu S, Su L, Liu X, Zhang X, Chen Z, Liu C, Hong N, Li Y, Long Y. Recognizing blood pressure patterns in sedated critically ill patients on mechanical ventilation by spectral clustering. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1404. [PMID: 34733956 PMCID: PMC8506777 DOI: 10.21037/atm-21-2806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 08/06/2021] [Indexed: 11/10/2022]
Abstract
Background Blood pressure is a critical therapeutic goal in intensive care unit (ICU). One important factor influencing blood pressure are analgesia and sedation. Analgesic and sedative drugs are commonly used in critically ill patients. These drugs affect blood pressure by reducing the tension of the venous system, the cardiac preload, and cardiac output and inhibiting cardiac functions. Consequently, vasoactive agents are commonly used to increase blood pressure. The indications for the usage of vasoactive agents are unequivocal. However, opinions on when to stop raising blood pressure vary. This study explored the relationship between blood pressure and sedation. Methods Patients in the Multiparameter Intelligent Monitoring in Intensive Care-III (MIMIC) database who had received mechanical ventilation, had been administered sedative analgesics during their ICU stay, and met the inclusion criteria were included in this study. The mean arterial pressure (MAP) tendency patterns were identified using spectral clustering and visualized using the t-distributed Stochastic Neighbor Embedding (t-SNE) algorithm. The 28-day mortality rates of patients with different MAP patterns during their first 24 hours in the ICU and their sedation levels were calculated in the crosstab. Results Fourteen thousand seven hundred and eighty-five patients from the MIMIC-III database were included in this study. Three MAP patterns were identified by spectral clustering. The median MAP of the low, moderate, and high MAP groups was 71.2, 80.4, and 97.6 mmHg, respectively. The 28-day mortality rate of patients in the moderate MAP group (13.0%) was lower than that of patients in the low (16.6%) and high (15.6%) MAP groups. No difference was found in the 28-day mortality rate between the low and high MAP groups. Dynamic changes in blood pressure at different sedation depths were also examined. Notably, compared with light and moderate sedation level, patients in the deep sedation group, especially those in the high MAP group (48.5%), had a higher 28-day mortality rate (36.5%). Conclusions Low MAP in the first 24 hours in ICU indicates a high possibility of poor prognosis for critically ill patients on mechanical ventilation. For patients under deep sedation, maintaining a high mean arterial pressure also indicates poor prognosis. A personalized MAP target should be determined according to the severity of illness and level of sedation for each patient.
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Affiliation(s)
- Shengjun Liu
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Longxiang Su
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Xin Liu
- Department of Electronic Engineering, Tsinghua University, Beijing, China
| | - Xueqian Zhang
- Department of Electronic Engineering, Tsinghua University, Beijing, China
| | - Zuyu Chen
- Department of Electronic Engineering, Tsinghua University, Beijing, China
| | - Chun Liu
- Digital Health China Technologies Co., Ltd., Beijing, China
| | - Na Hong
- Digital Health China Technologies Co., Ltd., Beijing, China
| | - Yali Li
- Department of Electronic Engineering, Tsinghua University, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
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Zhang W, Tang Y, Liu H, Yuan LP, Wang CC, Chen SF, Huang J, Xiao XY. Risk prediction models for intensive care unit-acquired weakness in intensive care unit patients: A systematic review. PLoS One 2021; 16:e0257768. [PMID: 34559850 PMCID: PMC8462700 DOI: 10.1371/journal.pone.0257768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 09/09/2021] [Indexed: 12/23/2022] Open
Abstract
Background and objectives Intensive care unit-acquired weakness (ICU-AW) commonly occurs among intensive care unit (ICU) patients and seriously affects the survival rate and long-term quality of life for patients. In this systematic review, we synthesized the findings of previous studies in order to analyze predictors of ICU-AW and evaluate the discrimination and validity of ICU-AW risk prediction models for ICU patients. Methods We searched seven databases published in English and Chinese language to identify studies regarding ICU-AW risk prediction models. Two reviewers independently screened the literature, evaluated the quality of the included literature, extracted data, and performed a systematic review. Results Ultimately, 11 studies were considered for this review. For the verification of prediction models, internal verification methods had been used in three studies, and a combination of internal and external verification had been used in one study. The value for the area under the ROC curve for eight models was 0.7–0.923. The predictor most commonly included in the models were age and the administration of corticosteroids. All the models have good applicability, but most of the models are biased due to the lack of blindness, lack of reporting, insufficient sample size, missing data, and lack of performance evaluation and calibration of the models. Conclusions The efficacy of most models for the risk prediction of ICU-AW among high-risk groups is good, but there was a certain bias in the development and verification of the models. Thus, ICU medical staff should select existing models based on actual clinical conditions and verify them before applying them in clinical practice. In order to provide a reliable basis for the risk prediction of ICU-AW, it is necessary that large-sample, multi-center studies be conducted in the future, in which ICU-AW risk prediction models are verified.
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Affiliation(s)
- Wei Zhang
- Department of Neurosurgery Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Yun Tang
- Department of Neurosurgery Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
- * E-mail:
| | - Huan Liu
- Department of Blood Purification Center, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Li ping Yuan
- Department of Nursing, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Chu chu Wang
- Department of Neurosurgery Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Shu fan Chen
- Department of Neurosurgery Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Jin Huang
- Department of Neurosurgery Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Xin yuan Xiao
- Department of Neurosurgery Intensive Care Unit, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
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Nakanishi N, Takashima T, Oto J. Muscle atrophy in critically ill patients : a review of its cause, evaluation, and prevention. THE JOURNAL OF MEDICAL INVESTIGATION 2021; 67:1-10. [PMID: 32378591 DOI: 10.2152/jmi.67.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Critically ill patients exhibit prominent muscle atrophy, which occurs rapidly after ICU admission and leads to poor clinical outcomes. The extent of atrophy differs among muscles as follows: upper limb: 0.7%-2.4% per day, lower limb: 1.2%-3.0% per day, and diaphragm 1.1%-10.9% per day. This atrophy is caused by numerous risk factors such as inflammation, immobilization, nutrition, hyperglycemia, medication, and mechanical ventilation. Muscle atrophy should be monitored noninvasively by ultrasound at the bedside. Ultrasound can assess muscle mass in most patients, although physical assessment is limited to almost half of all critically ill patients due to impaired consciousness. Important strategies to prevent muscle atrophy are physical therapy and electrical muscular stimulation. Electrical muscular stimulation is especially effective for patients with limited physical therapy. Regarding diaphragm atrophy, mechanical ventilation should be adjusted to maintain spontaneous breathing and titrate inspiratory pressure. However, the sufficient timing and amount of nutritional intervention remain unclear. Further investigation is necessary to prevent muscle atrophy and improve long-term outcomes. J. Med. Invest. 67 : 1-10, February, 2020.
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Affiliation(s)
- Nobuto Nakanishi
- Emergency and Critical Care Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima 770-8503, Japan
| | - Takuya Takashima
- Emergency and Critical Care Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima 770-8503, Japan
| | - Jun Oto
- Emergency and Disaster Medicine, Tokushima University Hospital, 2-50-1 Kuramoto, Tokushima 770-8503, Japan
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Matsukawa S, Kai S, Seo H, Suzuki K, Fukuda K. Activation of the β-adrenergic receptor exacerbates lipopolysaccharide-induced wasting of skeletal muscle cells by increasing interleukin-6 production. PLoS One 2021; 16:e0251921. [PMID: 34003837 PMCID: PMC8130926 DOI: 10.1371/journal.pone.0251921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/05/2021] [Indexed: 11/18/2022] Open
Abstract
The skeletal muscle mass has been shown to be affected by catecholamines, such as epinephrine (Epi), norepinephrine (NE), and isoproterenol (ISO). On the other hand, lipopolysaccharide (LPS), one of the causative substances of sepsis, induces muscle wasting via toll-like receptors expressed in skeletal muscle. Although catecholamines are frequently administered to critically ill patients, it is still incompletely understood how these drugs affect skeletal muscle during critical illness, including sepsis. Herein, we examined the direct effects of catecholamines on LPS-induced skeletal muscle wasting using the C2C12 myoblast cell line. Muscle wasting induced by catecholamines and/or LPS was analyzed by the use of the differentiated C2C12 myotubes, and its underlying mechanism was explored by immunoblotting analysis, quantitative reverse transcription polymerase chain reaction (qRT-PCR), enzyme-linked immunosorbent assay (ELISA), and the TransAM kit for p-65 NF-κB. Epi augmented myosin heavy chain (MHC) protein loss and reduction of the myotube diameter induced by LPS. LPS induced C/EBPδ protein, Atrogin-1 and inteleukin-6 (IL-6), and these responses were potentiated by Epi. An IL-6 inhibitor, LMT28, suppressed the potentiating effect of Epi on the LPS-induced responses. NF-κB activity was induced by LPS, but was not affected by Epi and recombinant IL-6, and the NF-κB inhibitor, Bay 11–7082, abolished Atrogin-1 mRNA expression induced by LPS with or without Epi. NE and ISO also potentiated LPS-induced IL-6 and Atroign-1 mRNA expression. Carvedilol, a nonselective β-adrenergic receptor antagonist, suppressed the facilitating effects of Epi on the Atrogin-1 mRNA induction by LPS, and abolished the effects of Epi on the MHC protein loss in the presence of LPS. It was concluded that Epi activates the β-adrenergic receptors in C2C12 myotubes and the IL-6-STAT3 pathway, leading to the augmentation of LPS-induced activation of the NF-κB- C/EBPδ-Atrogin-1 pathway and to the exacerbation of myotube wasting.
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Affiliation(s)
- Shino Matsukawa
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Shinichi Kai
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
- * E-mail:
| | - Hideya Seo
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Kengo Suzuki
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Kazuhiko Fukuda
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
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Environmental Factors Affecting Early Mobilization and Physical Disability Post-Intensive Care: An Integrative Review Through the Lens of the World Health Organization International Classification of Functioning, Disability, and Health. Dimens Crit Care Nurs 2021; 40:92-117. [PMID: 33961378 DOI: 10.1097/dcc.0000000000000461] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Early mobilization (EM) is one of few potential protective factors associated with reduced physical disability post-intensive care (PD PIC). However, only 45% of intensive care units (ICUs) in the United States routinely practice EM despite its recognized benefits. OBJECTIVES To analyze the evidence on the relationship between critical care EM, PD PIC, and environmental factors, using the theoretical lens of the World Health Organization's (WHO's) International Classification of Functioning, Disability, and Health (ICF). METHOD The Whittemore and Knafl methodology for integrative reviews and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines were followed. Qualitative, quantitative, and mixed-methods studies (n = 38) that evaluated EM and 1 or more domains of the WHO ICF were included. Quality was appraised using the Mixed-Methods Appraisal Tool. Study characteristics were evaluated for common themes and relationships. The ICF domains and subdomains pertaining to each study were synthesized. RESULTS Early mobilization was related to improved functioning on the disability continuum of the WHO ICF. Early mobilization was influenced by several WHO ICF environmental factors. Dedicated physical and occupational therapy teams in the ICU, interdisciplinary rounds, and positive family and staff perception of EM facilitated intervention delivery. However, poor staffing levels, negative unit culture, perceived workload burden, and lack of equipment, education, and financial support impeded delivery of EM. DISCUSSION Early mobilization is a promising intervention that may reduce PD PIC. However, environmental factors negatively influence delivery of EM in the ICU. Several gaps in EM research limit its acceptability in ICU practice. Existing EM research is challenged by poor methodological quality. Further study is necessary to better understand the role of EM on PD PIC and improve patient outcomes following critical illness.
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Urinary Titin N-Fragment as a Biomarker of Muscle Atrophy, Intensive Care Unit-Acquired Weakness, and Possible Application for Post-Intensive Care Syndrome. J Clin Med 2021; 10:jcm10040614. [PMID: 33561946 PMCID: PMC7915692 DOI: 10.3390/jcm10040614] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/29/2021] [Accepted: 02/03/2021] [Indexed: 12/15/2022] Open
Abstract
Titin is a giant protein that functions as a molecular spring in sarcomeres. Titin interconnects the contraction of actin-containing thin filaments and myosin-containing thick filaments. Titin breaks down to form urinary titin N-fragments, which are measurable in urine. Urinary titin N-fragment was originally reported to be a useful biomarker in the diagnosis of muscle dystrophy. Recently, the urinary titin N-fragment has been increasingly gaining attention as a novel biomarker of muscle atrophy and intensive care unit-acquired weakness in critically ill patients, in whom titin loss is a possible pathophysiology. Furthermore, several studies have reported that the urinary titin N-fragment also reflected muscle atrophy and weakness in patients with chronic illnesses. It may be used to predict the risk of post-intensive care syndrome or to monitor patients' condition after hospital discharge for better nutritional and rehabilitation management. We provide several tips on the use of this promising biomarker in post-intensive care syndrome.
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30
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Jasiński T, Stefaniak J. COVID-19 and haemodynamic failure: a point of view on mechanisms and treatment. Anaesthesiol Intensive Ther 2020; 52:409-417. [PMID: 33327700 PMCID: PMC10183984 DOI: 10.5114/ait.2020.101813] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 11/29/2020] [Indexed: 11/17/2022] Open
Abstract
The SARS-CoV-2-related disease has an undoubted impact on the healthcare system. In the treatment of severe COVID-19 cases, the main focus is on respiratory failure. However, available data suggest an important contribution of haemodynamic impairment in the course of this disease. SARS-CoV-2 may affect the circulatory system in various ways that are universal for septic conditions. Nonetheless, unique features of this pathogen, e.g. direct insult leading to myocarditis and renin-angiotensin-aldosterone axis dysregulation, must be taken into account. Although current recommendations on COVID-19 resemble previous septic shock guidelines, special attention to haemodynamic monitoring and treatment is necessary. Regarding treatment, one must take into account the potential profound hypovolaemia of severe COVID-19 patients. Pharmacological cardiovascular support should follow existing guidelines and practice. Interesting concepts of decatecholaminisation and the effect of vasopressors on pulmonary circulation are also presented in this review on COVID-19-related haemodynamic failure.
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Affiliation(s)
- Tomasz Jasiński
- Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk, Poland
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31
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Wang W, Xu C, Ma X, Zhang X, Xie P. Intensive Care Unit-Acquired Weakness: A Review of Recent Progress With a Look Toward the Future. Front Med (Lausanne) 2020; 7:559789. [PMID: 33330523 PMCID: PMC7719824 DOI: 10.3389/fmed.2020.559789] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/11/2020] [Indexed: 12/16/2022] Open
Abstract
Intensive care unit-acquired weakness (ICU-AW), a common neuromuscular complication associated with patients in the ICU, is a type of skeletal muscle dysfunction that commonly occurs following sepsis, mobility restriction, hyperglycemia, and the use of glucocorticoids or neuromuscular blocking agents. ICU-AW can lead to delayed withdrawal of mechanical ventilation and extended hospitalization. Patients often have poor prognosis, limited mobility, and severely affected quality of life. Currently, its pathogenesis is uncertain, with unavailability of specific drugs or targeted therapies. ICU-AW has gained attention in recent years. This manuscript reviews the current research status of the epidemiology, pathogenesis, diagnosis, and treatment methods for ICU-AW and speculates the novel perspectives for future research.
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Affiliation(s)
- Wenkang Wang
- Department of Critical Care Medicine of the Third Affiliated Hospital (The First People's Hospital of Zunyi), Zunyi Medical University, Zunyi, China
| | - Chuanjie Xu
- Department of Critical Care Medicine of the Third Affiliated Hospital (The First People's Hospital of Zunyi), Zunyi Medical University, Zunyi, China
| | - Xinglong Ma
- Department of Critical Care Medicine of the Third Affiliated Hospital (The First People's Hospital of Zunyi), Zunyi Medical University, Zunyi, China
| | - Xiaoming Zhang
- Department of Molecular and Cellular Biology, Baylor College of Medicine Houston, Houston, TX, United States
| | - Peng Xie
- Department of Critical Care Medicine of the Third Affiliated Hospital (The First People's Hospital of Zunyi), Zunyi Medical University, Zunyi, China
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Early Mobilization of Patients Receiving Vasoactive Drugs in Critical Care Units: A Systematic Review. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2020. [DOI: 10.1097/jat.0000000000000140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gazmuri RJ, de Gomez CA. Septic shock patients with adequate tissue perfusion parameters still need the recommended minimal Mean Arterial Pressure: Not really. J Crit Care 2020; 56:308-310. [PMID: 32178832 DOI: 10.1016/j.jcrc.2020.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/08/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Raúl J Gazmuri
- Medicine, Physiology & Biophysics, Resuscitation Institute at Rosalind Franklin University of Medicine and Science, Critical Care Medicine, Captain James A. Lovell Federal Health Care Center, United States of America.
| | - Cristina Añez de Gomez
- Internal Medicine Physician, Northwestern Medicine Lake Forest Hospital, United States of America
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Vanhorebeek I, Latronico N, Van den Berghe G. ICU-acquired weakness. Intensive Care Med 2020; 46:637-653. [PMID: 32076765 PMCID: PMC7224132 DOI: 10.1007/s00134-020-05944-4] [Citation(s) in RCA: 247] [Impact Index Per Article: 61.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/16/2020] [Indexed: 01/04/2023]
Abstract
Critically ill patients often acquire neuropathy and/or myopathy labeled ICU-acquired weakness. The current insights into incidence, pathophysiology, diagnostic tools, risk factors, short- and long-term consequences and management of ICU-acquired weakness are narratively reviewed. PubMed was searched for combinations of “neuropathy”, “myopathy”, “neuromyopathy”, or “weakness” with “critical illness”, “critically ill”, “ICU”, “PICU”, “sepsis” or “burn”. ICU-acquired weakness affects limb and respiratory muscles with a widely varying prevalence depending on the study population. Pathophysiology remains incompletely understood but comprises complex structural/functional alterations within myofibers and neurons. Clinical and electrophysiological tools are used for diagnosis, each with advantages and limitations. Risk factors include age, weight, comorbidities, illness severity, organ failure, exposure to drugs negatively affecting myofibers and neurons, immobility and other intensive care-related factors. ICU-acquired weakness increases risk of in-ICU, in-hospital and long-term mortality, duration of mechanical ventilation and of hospitalization and augments healthcare-related costs, increases likelihood of prolonged care in rehabilitation centers and reduces physical function and quality of life in the long term. RCTs have shown preventive impact of avoiding hyperglycemia, of omitting early parenteral nutrition use and of minimizing sedation. Results of studies investigating the impact of early mobilization, neuromuscular electrical stimulation and of pharmacological interventions were inconsistent, with recent systematic reviews/meta-analyses revealing no or only low-quality evidence for benefit. ICU-acquired weakness predisposes to adverse short- and long-term outcomes. Only a few preventive, but no therapeutic, strategies exist. Further mechanistic research is needed to identify new targets for interventions to be tested in adequately powered RCTs.
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Affiliation(s)
- Ilse Vanhorebeek
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123, Brescia, Italy.,Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, 25123, Brescia, Italy
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Gazmuri RJ, de Gomez CA. From a pressure-guided to a perfusion-centered resuscitation strategy in septic shock: Critical literature review and illustrative case. J Crit Care 2020; 56:294-304. [PMID: 31926637 DOI: 10.1016/j.jcrc.2019.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 07/28/2019] [Accepted: 11/13/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE To support a paradigm shift in the management of septic shock from pressure-guided to perfusion-centered, expected to improve outcome while reducing adverse effects from vasopressor therapy and aggressive fluid resuscitation. MATERIAL AND METHODS Critical review of the literature cited in support of vasopressor use to achieve a predefined mean arterial pressure (MAP) of 65 mmHg and review of pertinent clinical trials and studies enabling deeper understanding of the hemodynamic pathophysiology supportive of a perfusion-centered approach, accompanied by an illustrative case. RESULTS Review of the literature cited by the Surviving Sepsis Campaign revealed lack of controlled clinical trials supporting outcome benefits from vasopressors. Additional literature review revealed adverse effects associated with vasopressors and worsened outcome in some studies. Vasopressors increase MAP primarily by peripheral vasoconstriction and in occasions by a modest increase in cardiac output when using norepinephrine. Thus, achieving the recommended MAP of 65 mmHg using vasopressors should not be presumed indicative that organ perfusion has been restored. It may instead create a false sense of hemodynamic stability hampering shock resolution. CONCLUSIONS We propose focusing the hemodynamic management of septic shock on reversing organ hypoperfusion instead of attaining a predefined MAP target as the key strategy for improving outcome.
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Affiliation(s)
- Raúl J Gazmuri
- Medicine, Physiology & Biophysics, Resuscitation Institute at Rosalind Franklin University of Medicine and Science, Critical Care Medicine and ICU, Captain James A. Lovell Federal Health Care Center, USA.
| | - Cristina Añez de Gomez
- Internal Medicine Physician, Northwestern Medical Group, Northwestern Medicine Lake Forrest Hospital, USA
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Watanabe S, Kotani T, Taito S, Ota K, Ishii K, Ono M, Katsukawa H, Kozu R, Morita Y, Arakawa R, Suzuki S. Determinants of gait independence after mechanical ventilation in the intensive care unit: a Japanese multicenter retrospective exploratory cohort study. J Intensive Care 2019; 7:53. [PMID: 31798888 PMCID: PMC6880493 DOI: 10.1186/s40560-019-0404-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 10/02/2019] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Gait independence is one of the most important factors related to returning home from the hospital for patients treated in the intensive care unit (ICU), but the factors affecting gait independence have not been clarified. This study aimed to determine the factors affecting gait independence at hospital discharge using a standardized early mobilization protocol that was shared by participating hospitals. MATERIALS AND METHODS Patients who entered the ICU from January 2017 to March 2018 were screened. The exclusion criteria were mechanical ventilation < 48 hours, age < 18, loss of gait independence before hospitalization, being treated for neurological issues, unrecoverable disease, unavailability of continuous data, and death during ICU stay. Basic attributes, such as age, ICU length of stay, information on early mobilization while in the ICU, Medical Research Council (MRC) sum-score at ICU discharge, incidence of ICU-acquired weakness (ICU-AW) and delirium, and the degree of gait independence at hospital discharge, were collected. Gait independence was determined using a mobility scale of the Barthel Index, and the factors that impaired gait independence at hospital discharge were investigated using a Cox proportional hazard regression analysis. RESULTS One hundred thirty-two patients were analyzed. In the univariate analysis, age, APACHE II score, duration of mechanical ventilation, ICU length of stay, incidence of delirium, and MRC sum-score at ICU discharge were extracted as significant. In the multivariate analysis, age (p = 0.014), MRC sum-score < 48 (p = 0.021), and delirium at discharge from ICU (p < 0.0001) were extracted as significant variables. CONCLUSIONS We found that age and incidence of ICU-AW and delirium were significantly related to impaired gait independence at hospital discharge.
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Affiliation(s)
- Shinichi Watanabe
- Department of Rehabilitation Medicine, National Hospital Organization, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-ku, Nagoya, Aichi 460-0001 Japan
| | - Toru Kotani
- Department of Intensive Care Medicine, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666 Japan
| | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Kohei Ota
- Department of Emergency and Critical Care Medicine, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima, 734-8551 Japan
| | - Kenzo Ishii
- Department of Anesthesia, Fukuyama City Hospital, 5-23-1, Zaou-tyo, Hukuyama, Hiroshima, 734-0971 Japan
| | - Mika Ono
- Department of Nursing, Nagoya University of Arts and Sciences, 4-1-1 Sannomaru, Naka-ku, Nagoya, Aichi 460-0001 Japan
| | - Hajime Katsukawa
- Japanese Society for Early Mobilization, 1-2-12 Kudankita, Tiyoda-ku, Tokyo, 102-0073 Japan
| | - Ryo Kozu
- Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8520 Japan
- Department of Rehabilitation Medicine, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8520 Japan
| | - Yasunari Morita
- Department of Critical Care Medicine, National Hospital Organization, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-ku, Nagoya, Aichi 460-0001 Japan
| | - Ritsuro Arakawa
- Department of Critical Care Medicine, National Hospital Organization, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-ku, Nagoya, Aichi 460-0001 Japan
| | - Shuichi Suzuki
- Department of Critical Care Medicine, National Hospital Organization, Nagoya Medical Center, 4-1-1 Sannomaru, Naka-ku, Nagoya, Aichi 460-0001 Japan
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37
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Files DC, Heinrich T, Shields KL, Love NJ, Brailer C, Bakhru RN, Purcell L, Flores L, Gibbs K, Miller GD, Morris PE, Berry MJ. A randomized pilot study of nitrate supplementation with beetroot juice in acute respiratory failure. Nitric Oxide 2019; 94:63-68. [PMID: 31669503 DOI: 10.1016/j.niox.2019.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/01/2019] [Accepted: 10/24/2019] [Indexed: 02/04/2023]
Abstract
Nitrate rich beetroot juice (BRJ) can enhance nitric oxide signaling, leading to improved physical function in healthy and diseased populations, but its safety and biologic efficacy have not been evaluated in a critically ill population. We randomized 22 previously functional acute respiratory failure patients to either BRJ or placebo daily until day 14 or discharge. We measured blood nitrate and nitrite levels and quantified strength and physical function at intensive care unit (ICU) and hospital discharge. Participants were predominantly male (54%), aged 68.5 years with an APACHE III score of 62. BRJ increased plasma nitrate (mean 219.2 μM increase, p = 0.002) and nitrite levels (mean 0.144 μM increase, p = 0.02). We identified no adverse events. The unadjusted and adjusted effect sizes of the intervention on the short physical performance battery were small (d = 0.12 and d = 0.17, respectively). In this pilot trial, administration of BRJ was feasible and safe, increased blood nitrate and nitrate levels, but had a small effect on physical function. Future studies could evaluate the clinical efficacy of BRJ as a therapy to improve physical function in survivors of critical illness.
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Affiliation(s)
- D Clark Files
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA; Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA.
| | - Timothy Heinrich
- Department of Health & Exercise Science, Wake Forest University: Winston-Salem, NC, 27109, USA
| | - Katherine L Shields
- Department of Health & Exercise Science, Wake Forest University: Winston-Salem, NC, 27109, USA
| | - Nathan J Love
- Department of Health & Exercise Science, Wake Forest University: Winston-Salem, NC, 27109, USA
| | - Carly Brailer
- Department of Health & Exercise Science, Wake Forest University: Winston-Salem, NC, 27109, USA
| | - Rita N Bakhru
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA; Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Lina Purcell
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Lori Flores
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Kevin Gibbs
- Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA; Critical Illness Injury and Recovery Research Center, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Gary D Miller
- Department of Health & Exercise Science, Wake Forest University: Winston-Salem, NC, 27109, USA
| | - Peter E Morris
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, USA
| | - Michael J Berry
- Department of Health & Exercise Science, Wake Forest University: Winston-Salem, NC, 27109, USA
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Vincent JL. The continuum of critical care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:122. [PMID: 31200740 PMCID: PMC6570628 DOI: 10.1186/s13054-019-2393-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 03/14/2019] [Indexed: 12/24/2022]
Abstract
Until relatively recently, critical illness was considered as a separate entity and the intensive care unit (ICU), often a little cut-off from other areas of the hospital, was in many cases used as a last resort for patients so severely ill that it was no longer possible to care for them on the general ward. However, we are increasingly realizing that critical illness should be seen as just one part of the patient's disease trajectory and how the patient is managed before and after ICU admission has an important role to play in optimizing outcomes. Identifying critical illness early, before it reaches a stage where it is life-threatening, is a challenge and requires a combination of improved and more frequent or continuous monitoring of at-risk patients, staff training to recognize when a patient is deteriorating, a system to "call for help," and an effective response to that call. Critical care doctors are now widely available 24 h a day for consultation, and many hospitals have rapid response or medical emergency teams composed of staff trained in intensive care and with resuscitation skills who can attend patients on the ward who have been identified to be deteriorating, assess them to determine the need for ICU admission, and initiate further tests and/or initial therapy. Early intensivist input may also be important for patients undergoing interventions that are likely to result in ICU admission, e.g., transplantation or cardiac surgery. The patient's continuum after ICU discharge must also be taken into account during their ICU stay, with attempts made to limit the longer-term physical and psychological consequences of critical illness as much as possible. Minimal sedation, good communication, and early mobilization are three factors that can help patients survive their ICU stay with minimal sequelae.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, 808 Route de Lennik, 1070, Brussels, Belgium.
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Druml W, Druml C. [Overtreatment in intensive care medicine]. Med Klin Intensivmed Notfmed 2019; 114:194-201. [PMID: 30918983 DOI: 10.1007/s00063-019-0548-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 01/02/2019] [Indexed: 12/31/2022]
Abstract
Overtreatment, which is therapy that is neither indicated nor desired by the patient ("non-beneficial"), presents an inherent and huge problem of modern medicine and intensive care medicine in particular. Overtreatment concerns all aspects of intensive care medicine, may start already before admission at the emergency scene, the inappropriate admission to the intensive care unit, overuse in diagnostics and especially in blood sampling, in invasive procedures and in organ support therapies. It manifests itself as "too much" in sedation, relaxation, volume therapy, hemodynamic support, blood products, antibiotics and other drugs and nutrition. Most importantly, overtreatment concerns the care of the patients at the end of life when a causal therapy is no longer available. Overtreatment also has important ethical implications and violates the four fundamental principles of medical ethics. It disregards the autonomy, dignity and integrity of the patient, is by definition nonbeneficial and increases pain, suffering, prolongs dying, increases sorrow of relatives, imposes frustration for the caregivers, disregards distributive justice and harms society in general by wasting principally limited resources. Overtreatment has also become an important legal issue and because of imposing inappropriate suffering may lead to prosecution. Overtreatment is poor medicine, is no trivial offence, all must continuously work together to reduce or avoid overtreatment.
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Affiliation(s)
- W Druml
- Klinik für Innere Medizin III, Abteilung für Nephrologie, Allgemeines Krankenhaus Wien, Wien, Österreich
| | - C Druml
- Ethik, Sammlungen und Geschichte der Medizin, Medizinische Universität Wien, Währinger Gürtel 25, 1090, Wien, Österreich.
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