Effect of non-sedation on physical function in survivors of critical illness - A substudy of the NONSEDA randomized trial

Musculoskeletal health state and physical function of intensive care unit survivors: protocol for a UK multicentre prospective cohort study (the MSK-ICU study)

INTRODUCTION

Survivors of critical illness frequently experience long-term physical impairment, decreased health-related quality of life and low rates of return to employment. There has been limited investigation of the underlying problems affecting physical function post-intensive care unit (ICU) admission. Musculoskeletal (MSK) conditions may be complex in presentation, with ICU survivors potentially at greater risk of their development due to the rapid muscle mass loss seen in ICU. The MSK health state of ICU survivors and its impact on physical function remain largely unknown. The aim of the MSK-ICU study is to determine and characterise the MSK health state of ICU survivors 6 months following admission to ICU, in order to inform development of targeted rehabilitation interventions.

METHODS AND ANALYSIS

The MSK-ICU study is a multicentre prospective longitudinal cohort study, evaluating the MSK health state of ICU survivors 6 months after admission to ICU. The study consists of a primary study and two substudies. The primary study will be a telephone follow-up of adults admitted to ICU for more than 48 hours, collecting data on MSK health state, quality of life, employment, anxiety and depression and symptoms of post-traumatic stress disorder. The planned sample size is 334 participants. Multivariable regression will be used to identify prognostic factors for a worse MSK health state, as measured by the MSK-Health Questionnaire. In substudy 1, participants who self-report any MSK problem will undergo a detailed, in-person MSK physical assessment of pain, peripheral joint range of movement and strength. In substudy 2, participants reporting a severe MSK problem will undergo a detailed physical assessment of mobility, function and muscle architecture.

ETHICS AND DISSEMINATION

Ethical approval has been obtained through the North of Scotland Research Ethics Committee 2 (21/NS/0143). We aim to disseminate the findings through international conferences, international peer-reviewed journals and social media.

TRIAL REGISTRATION NUMBER

ISRCTN24998809.

In-Hospital Depressed Level of Consciousness and Long-Term Functional Outcomes in ICU Survivors

OBJECTIVES

Among critically ill patients, acutely depressed level of consciousness is associated with mortality, but its relationship to long-term outcomes such as disability and physical function is unknown. We investigated the relationship of level of consciousness during hospitalization with long-term disability and physical function in ICU survivors.

DESIGN

Multi-center observational cohort study.

SETTING

Medical or surgical ICUs at five U.S. centers.

PATIENTS

Adult survivors of respiratory failure or shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Depressed level of consciousness during hospitalization was defined using the Richmond Agitation Sedation Scale (RASS) score (including all negative scores) by calculating the area under the curve using linear interpolation. Sedative-associated level of consciousness was similarly defined for all hospital days that sedation was received. We measured disability in basic activities of daily living (BADLs), instrumental activities of daily living (IADLs), discharge destination, and self-reported physical function. In separate models, we evaluated associations between these measures of level of consciousness and outcomes using multivariable regression, adjusted for age, sex, race, body mass index, education level, comorbidities, baseline frailty, baseline IADLs and BADLs, hospital type (civilian vs veteran), modified mean daily Sequential Organ Failure Assessment score, duration of severe sepsis, duration of mechanical ventilation, and hospital length of stay. Of the 1,040 patients enrolled in the ICU, 781 survived to hospital discharge. We assessed outcomes in 624 patients at 3 months and 527 patients at 12 months. After adjusting for covariates, there was no association between depressed level of consciousness (total or sedation-associated) with BADLs or IADLs at either 3- or 12-month follow-up. There was also no association with self-reported physical function at 3 or 12 months or with discharge destination.

CONCLUSIONS

Depressed level of consciousness, as defined by the RASS, was not associated with disability or self-reported physical function. Future studies should investigate additional modifiable in-hospital risk factors for disability and poor physical function following critical illness.

Failure of non-sedation strategy in critically ill, mechanically ventilated patients - a retrospective, post-hoc analysis of the NONSEDA trial

PURPOSE

There is a growing awareness on minimizing sedation in ICUs. In the NONSEDA trial 700 critically ill patients were randomized to light sedation or non-sedation during mechanical ventilation. Approximately 40% of patients randomized to non-sedation needed sedation. The aim of this study is to obtain knowledge on patients, who experienced failure of non-sedation.

MATERIALS AND METHODS

This study is a retrospective post-hoc analysis of the NONSEDA trial. Patients, who were randomized to non-sedation are sub-divided into those who did not require sedation during mechanical ventilation ("non-sedation success"), and those who needed continuous sedation at least once ("non-sedation failure").

RESULTS

348 patients were randomized to non-sedation, 199 experienced non-sedation success, whereas 149 experienced non-sedation failure. Patients in the two groups were comparable with regards to age, BMI, disease severity scores and admission diagnoses. Patients with non-sedation failure were more often male. Propofol was mainly used as rescue sedation. Patients with non-sedation failure had less days alive without sedation, coma, delirium, organ support, mechanical ventilation, ICU- and hospital admission. Mortality and long-term outcomes did not differ between groups.

CONCLUSION

Patients with non-sedation success had better in-hospital outcomes, but mortality and long-term outcomes were not affected by success or failure of non-sedation.

Musculoskeletal complications following critical illness: A scoping review

PURPOSE

To explore the extent to which musculoskeletal (MSK) complications have been reported following critical illness, identifying evidence gaps and providing recommendations for future research.

MATERIALS AND METHODS

We searched five databases from January 1st 2000 to March 31st 2021. We included published original research reporting MSK complications in patients discharged from hospital following an admission to an intensive care unit (ICU). Two reviewers independently screened English language articles for eligibility. Data extracted included the MSK area of investigation and MSK outcome measures. The overall quality of study was evaluated against standardised reporting guidelines.

RESULTS

4512 titles were screened, and 32 met the inclusion criteria. Only one study included was interventional, with the majority being prospective cohort studies (n = 22). MSK complications identified included: muscle weakness or atrophy, chronic pain, neuromuscular dysfunction, peripheral joint impairment and fracture risk. The quality of the overall reporting in the studies was deemed adequate.

CONCLUSIONS

We identified a heterogenous body of literature reporting a high prevalence of a variety of MSK complications extending beyond muscle weakness, therefore future investigation should include evaluations of more than one MSK area. Further investigation of MSK complications could inform the development of future post critical illness rehabilitation programs.