Does ICU length of stay influence quality of life?

The 2023 WSES guidelines on the management of trauma in elderly and frail patients

BACKGROUND

The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.

METHODS

Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.

RESULTS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared.

CONCLUSIONS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

Impact of COVID-19 critical illness on functional status, fatigue symptoms, and health-related quality of life one-year after hospital discharge: a systematic review and meta-analysis

Purpose: To estimate the prevalence and severity of impairments in functional status, fatigue, and health-related quality of life (HRQoL) among critical COVID-19 survivors one-year after hospital discharge. Methods: A systematic review was conducted following PRISMA statement and registered in PROSPERO (CRD42021258356), with searches in eight databases. Observational studies were selected. The prevalence meta-analysis of abnormalities was performed using random-effects models. Risk of bias was evaluated using the National Heart, Lung, and Blood Institute tool. Results: Twenty studies were included, with data collected between 12 and 13.5 months after hospital discharge and a total of 1828 participants. Of these, 71% were men, and 77.7% were intubated in the intensive care unit (ICU). Impairments and sequelae were identified in varying prevalence and degrees, with greater impact on functional capacity and physical components of fatigue and HRQoL. The prevalence of abnormalities of 32.3% [95% CI 23.9; 41.9] found in the meta-analysis is substantially high. Most studies were classified as having fair and poor quality. Conclusion: Critical COVID-19 survivors experience impairments in functional status, fatigue, and HRQoL to varying degrees one-year after hospital discharge, particularly among patients who stayed in the ICU and on MV for a prolonged period.

Impact of length of donor ICU stay on outcome of patients after pediatric liver transplantation with whole and ex situ split liver grafts

BACKGROUND

Patients who have a prolonged stay in the intensive care unit (ICU) are often excluded for organ donation because of supposed deleterious effects of a lengthy ICU stay. We aimed to determine the effects of a prolonged donor stay in the ICU on the outcome of liver transplantation (LT) in children.

METHODS

Retrospective review of 89 pediatric LT patients, age 0-18 years, period 2003-2018, including patients having undergone whole organ or in situ split LT. The patients were divided into two groups according to the donor length of stay in the ICU. A prolonged stay was defined as >5 days. Recipient, graft, and donor characteristics were compared; outcome parameters included recipient and graft survival rates and postoperative complications.

RESULTS

Group short (donor ICU stay <5 days) included 75 patients, group long (donor ICU stay >5 days) 14 patients. Baseline characteristics between recipients did not differ. Donors in group long had significantly more infectious complications and a higher gamma glutamyl transferase (gGT) the day of organ recovery. Incidence of biliary complications post-LT was significantly higher in group long (p = .029). Patient and graft survival rates did not differ significantly between groups.

CONCLUSIONS

Donors with a prolonged stay in the ICU should still be considered for liver donation if they fulfill most other selection criteria. Recipients from donors having stayed in ICU >5 days may be at increased risk of biliary complications.

Can a Dyadic Resiliency Program Improve Quality of Life in Cognitively Intact Dyads of Neuro-ICU Survivors and Informal Caregivers? Results from a Pilot RCT

BACKGROUND

Neuro-ICU hospitalization for an acute neurological illness is often traumatic and associated with heightened emotional distress and reduced quality of life (QoL) for both survivors and their informal caregivers (i.e., family and friends providing unpaid care). In a pilot study, we previously showed that a dyadic (survivor and caregiver together) resiliency intervention (Recovering Together [RT]) was feasible and associated with sustained improvement in emotional distress when compared with an attention placebo educational control. Here we report on changes in secondary outcomes assessing QoL.

METHODS

Survivors (n = 58) and informal caregivers (n = 58) completed assessments at bedside and were randomly assigned to participate together as a dyad in the RT or control intervention (both 6 weeks, two in-person sessions at bedside and four sessions via live video post discharge). We measured QoL domain scores (physical health, psychological, social relations, and environmental), general QoL, and QoL satisfaction using the World Health Organization Quality of Life Abbreviated Instrument at baseline, post treatment, and 3 months' follow-up. We conducted mixed model analyses of variance with linear contrasts to estimate (1) within-group changes in QoL from baseline to post treatment and from post treatment to 3 months' follow-up and (2) between-group differences in changes in QoL from baseline to post treatment and from post treatment to 3 months' follow-up.

RESULTS

We found significant within-group improvements from baseline to post treatment among RT survivors for physical health QoL (mean difference 1.73; 95% confidence interval [CI] 0.39-3.06; p = 0.012), environmental QoL (mean difference 1.29; 95% CI 0.21-2.36; p = 0.020), general QoL (mean difference 0.55; 95% CI 0.13-0.973; p = 0.011), and QoL satisfaction (mean difference 0.87; 95% CI 0.36-1.37; p = 0.001), and those improvements sustained through the 3-month follow-up. We found no significant between-group improvements for survivors or caregivers from baseline to post treatment or from post treatment to 3 months' follow-up for any QoL variables (i.e., domains, general QoL, and QoL satisfaction together).

CONCLUSIONS

In this pilot study, we found improved QoL among survivors, but not in caregivers, who received RT and improvements sustained over time. These RT-related improvements were not significantly greater than those observed in the control. Results support a fully powered randomized controlled trial to allow for a definitive evaluation of RT-related effects among dyads of survivors of acute brain injury and their caregivers.

Prevalence and experience of fatigue in survivors of critical illness: a mixed-methods systematic review

We conducted a mixed methods systematic review to investigate the prevalence, experience and management of fatigue in survivors of critical illness. We identified 76 studies investigating fatigue or vitality in adults discharged from an intensive care unit and split the extracted data into three datasets: vitality scores from the Short Form Health Survey-36 (n = 54); other quantitative data (n = 19); and qualitative data (n = 9). We assessed methodological quality using critical appraisal skills programme tools. We adopted a segregated approach to mixed-methods synthesis. In a final step, we attributed combined results to one of four qualitative themes: prevalence and severity; contributing factors; impacts on quality of life; and assessment and management. Prevalence of fatigue ranged from 13.8 to 80.9%. Short Form Health Survey-36 vitality scores were commonly used as a marker of fatigue. Vitality scores reached a nadir approximately one month following ICU discharge (mean (SD) 56.44 (32.30); 95%CI 52.92-59.97). They improved over time but seldom reached reference population scores. Associated biological, disease-related and psychological factors included age, poor pre-morbid status, sleep and psychological disturbance. Qualitative data highlight the profound negative impact of fatigue on survivors' quality of life. Survivors seldom had any information provided on the potential impact of fatigue. No fatigue assessment tools specific to critical illness or evidence-based interventions were reported. Fatigue is highly prevalent in survivors of critical illness, and negatively impacts recovery. Further research on developing fatigue assessment tools specifically for critically ill patients and evaluating the impact of pharmacological and non-pharmacology interventions is needed.

Health-Related Quality of Life Measured by EQ-5D in Relation to Hospital Stay and Readmission in Elderly Patients Hospitalized for Acute Illness

We evaluated the predictability of self-reported Health-related quality of life (HRQoL) assessed by the 3-level 5-dimensional Euro-Quality of Life tool (EQ-5D-3L) and the EQ-Visual Analog Scale (EQ-VAS) on clinical outcomes of elderly patients who were admitted to an acute geriatric ward. A total of 102 participants (56.9% men) with a median age of 81.0 years (interquartile range or IQR: 76.0–85.3 years) were studied. The age-adjusted Charlson comorbidity index was 5.0 (IQR: 4.0–6.0) with a median length of stay (LOS) of 9.0 days (IQR: 7.0–15.0 days). No death occurred during hospitalization, and within 30 days after discharge, 15 patients were readmitted. During hospitalization, the EQ-5D-3L index was 0.440 at admission and that improved to 0.648 at discharge (p < 0.001). EQ-VAS scores also improved similarly from 60 to 70 (p < 0.001). Physical, cognitive function, frailty parameters (hand grip strength and walking speed), and nutritional status at admission all improved significantly during hospitalization and were related to EQ-5D-3L index or EQ-VAS scores at discharge. After controlling for relevant factors, EQ-5D-3L index at admission was found to be associated with LOS. In addition, EQ-VAS was marginally related to readmission. HRQoL assessment during hospitalization could be useful to guide clinical practice and to improve outcome.

Survival and Quality of Life after Prolonged Intensive Care Unit Stay

There are few data on long-term outcomes in mixed groups of intensive care unit (ICU) patients with prolonged stays. We evaluated the relationship between length of stay in the ICU and long-term outcome in all patients admitted to our 31-bed department of medico-surgical intensive care over a one-year period who stayed in the department for more than 10 days (n=189, 7% of all ICU admissions). Mortality increased with length of stay from 1 to 10 days (1 day 5%, 5 days 15%, 9 days 24%, 10 days 33%) but remained stable at about 35% for longer ICU stays. In the long-stay patients, the most common reasons for ICU admission were intracranial bleeding (23%), polytrauma (14%), respiratory failure (13%) and septic shock (11%). The main reasons for prolonged ICU stay were ventilator dependency (40%), infectious complications (23%) and coma (16%). Long-stay patients had a 65% ICU survival, 55% hospital survival and 37% one-year survival. At one-year follow-up, 73% of surviving patients reported no or minor persistent physical complaints compared to before the acute illness; 27% had a major functional impairment, including 8% who required daily assistance. In conclusion, in ICU patients, mortality increases with length of stay up to 10 days. Patients staying in the ICU for more than 10 days have a relatively good long-term survival. Most survivors have an acceptable quality of life.

Investigation of the Relationship Between the Burden of Raised ICP and the Length of Stay in a Neuro-Intensive Care Unit

OBJECTIVES

Raised intracranial pressure (ICP) is well known to be indicative of a poor outcome in traumatic brain injury (TBI). This phenomenon was quantified using a pressure time index (PTI) model of raised ICP burden in a paediatric population. Using the PTI methodology, this pilot study is aimed at investigating the relationship between raised ICP and length of stay (LOS) in adults admitted to a neurological intensive care unit (neuro-ICU).

MATERIALS AND METHODS

In 10 patients admitted to the neuro-ICU following TBI, ICP was measured and data from the first 24 h were analysed. The PTI is a bounded area under the curve, where the bound is the threshold limit of interest for the signal. The upper bound of 20 mmHg for ICP is commonly used in clinical practice. To fully investigate the relationship between ICP and LOS, further bounds from 1 to 40 mmHg were used during the PTI calculations. A backwards step Poisson regression model with a log link function was used to find the important thresholds for the prediction of full LOS, measured in hours, in the neuro-ICU.

RESULTS

The fit was assessed using a Chi-squared deviance goodness of fit method, which showed a non-significant p value of 0.97, indicating a correctly specified model. The backwards step strategy, minimising the model's Akaike information criteria (AIC) at each change, found that levels 13-16, 18 and 20-21 combined were the most predictive. From this model it can be shown that for every 1 mmHg/h increase in burden, as measured by the PTI, the LOS has a base exponential increase of approximately 2 h, with the largest increases in the LOS given at the 20-mmHg threshold level.

CONCLUSIONS

This model demonstrates that increased duration of raised ICP in the early monitoring period is associated with a prolonged LOS in the neuro-ICU. Further validation of the PTI model in a larger cohort is currently underway as part of the CHART-ADAPT project. Second, further adjustment with known predictors of outcome, such as severity of injury, would help to improve the fit and validate the current combination of predictors.

Clinical Characteristics and Outcomes of Surgical Patients with Intensive Care Unit Lengths of Stay of 90 Days and Greater

BACKGROUND

The aim of this study was to evaluate the influence of prolonged length of stay in an intensive care unit (ICU) on the mortality and morbidity of surgical patients.

METHODS

We performed a monocentric and retrospective observational study in the surgical critical care unit of the department of surgery at the Medical Center of the University of Freiburg, Germany. Clinical data was collected from patients assigned to the ICU with a length of stay (LOS) of 90 days and greater.

RESULTS

From the total of the 19 patients with ICU LOS over 90 days, ten patients died in the ICU whereas nine patients were discharged to the normal ward. The ICU mortality rate was 52%. The overall survival one year after ICU discharge was 32%. Regarding factors affecting mortality of the patients, significantly higher mortality was associated with age of the patients at the time point of the ICU admission and with postoperative need of renal replacement therapy.

CONCLUSIONS

We found a high but in our opinion acceptable mortality rate in surgical patients with ICU LOS of 90 days and greater. We identified age and the need of renal replacement therapy as risk factors for mortality.

Health related quality of life assessment in acute coronary syndrome patients: the effectiveness of early phase I cardiac rehabilitation

BACKGROUND

Acute Coronary Syndrome (ACS) is one of the most burdensome cardiovascular diseases in terms of the cost of interventions. The Cardiac Rehabilitation Programme (CRP) is well-established in improving clinical outcomes but the assessment of actual clinical improvement is challenging, especially when considering pharmaceutical care (PC) values in phase I CRP during admission and upon discharge from hospital and phase II outpatient interventions. This study explores the impact of pharmacists' interventions in the early stages of CRP on humanistic outcomes and follow-up at a referral hospital in Malaysia.

METHODS

We recruited 112 patients who were newly diagnosed with ACS and treated at the referral hospital, Sarawak General Hospital, Malaysia. In the intervention group (modified CRP), all medication was reviewed by the clinical pharmacists, focusing on drug indication; understanding of secondary prevention therapy and adherence to treatment strategy. We compared the "pre-post" quality of life (QoL) of three groups (intervention, conventional and control) at baseline, 6 months and 12 months post-discharge with Malaysian norms. QoL data was obtained using a validated version of Short-Form 36 Questionnaire (SF-36). Analysis of variance (ANOVA) with repeated measure tests was used to compare the mean differences of scores over time.

RESULTS

A pre-post quasi-experimental non-equivalent group comparison design was applied to 112 patients who were followed up for one year. At baseline, the physical and mental health summaries reported poor outcomes in all three groups. However, these improved gradually but significantly over time. After the 6-month follow-up, the physical component summary reported in the modified CRP (MCRP) participants was higher, with a mean difference of 8.02 (p = 0.015) but worse in the mental component summary, with a mean difference of -4.13. At the 12-month follow-up, the MCRP participants performed better in their physical component (PCS) than those in the CCRP and control groups, with a mean difference of 11.46 (p = 0.008), 10.96 (p = 0.002) and 6.41 (p = 0.006) respectively. Comparing the changes over time for minimal important differences (MICD), the MCRP group showed better social functioning than the CCRP and control groups with mean differences of 20.53 (p = 0.03), 14.47 and 8.8, respectively. In role emotional subscales all three groups showed significant improvement in MCID with mean differences of 30.96 (p = 0.048), 31.58 (p = 0.022) and 37.04 (p < 0.001) respectively.

CONCLUSION

Our results showed that pharmaceutical care intervention significantly improved HRQoL. The study also highlights the importance of early rehabilitation in the hospital setting. The MCRP group consistently showed better QoL, was more highly motivated and benefitted most from the CRP.

TRIAL REGISTRATION

Medical Research and Ethics Committee (MREC) Ministry of Health Malaysia, November 2007, NMRR-08-246-1401.

Long-term admission to the intensive care unit: a cost-benefit analysis

OBJECTIVE

To assess outcomes in long-term ICU patients, with follow-ups carried out at one year post discharge, in order to calculate the costs incurred by the hospital in relation to the benefits gained.

MATERIAL

Of 3639 patients consecutively admitted over the course of three years to ICU, 235 (6.5%) were assessed for the purposes of the study, having spent a period exceeding 20 days in intensive care.

METHOD

The survey tool used was the Spanish Minimum Data Set (MDS). The length of ICU stay and hospital stay following discharge from ICU were calculated, and one year post discharge the patient/next of kin was contacted in order to carry out a follow-up survey on survival and functional status (according to GOS-E scale).

RESULTS

The 235 study patients had a mean stay of 37 days, occupied 34% of ICU beds available and consumed 29% of the ICU's economic resources ($14,400,175). Their stay on hospital wards was (mean) 33 days. Mortality in ICU and on hospital wards was 40% higher amongst older patients, and those with a higher APACHE II and Charlson index score. Mortality rates were three times higher among neurosurgical patients: mortality at follow-up was 25%, and only 21% recovered an acceptable functional status.

CONCLUSIONS

Mortality rates in long-term ICU patients are high, both during their hospital stay and in the first year post discharge. Surviving patients do not exhibit a good level of recovery, and consume a large proportion of economic resources.

Quality of life after intensive care: a systematic review of the literature

OBJECTIVES

To evaluate quality of life at least 12 months after discharge from the intensive care unit of adult critically ill patients, to evaluate the methodology used to assess long-term quality of life, and to give an overview of factors influencing quality of life.

DATA SOURCES

EMBASE-PubMed, MEDLINE (OVID), SCI/Web of Science, the Cochrane Library, Google Scholar, and personal files.

DATA EXTRACTION

Data extraction was performed independently and cross-checked by two reviewers using a predefined data extraction form. Eligible studies were published between 1999 and 2009 and assessed quality of life ≥12 months after intensive care unit discharge by means of the Medical Outcomes Study 36-Item Short Form Health Survey, the RAND 36-Item Health Survey, EuroQol-5D, and/or the Nottingham Health Profile in adult intensive care unit patients.

DATA SYNTHESIS

Fifty-three articles (10 multicenters) were included, with the majority of studies performed in Europe (68%). The Medical Outcomes Study 36-Item Short Form Health Survey was used in 55%, and the EuroQol-5D, the Nottingham Health Profile, the RAND 36-Item Health Survey, or a combination was used in 21%, 9%, 8%, or 8%, respectively. A response rate of ≥80% was attained in 26 studies (49%). Critically ill patients had a lower quality of life than an age- and gender-matched population, but quality of life tended to improve over years. The worst reductions in quality of life were seen in cases of severe acute respiratory distress syndrome, prolonged mechanical ventilation, severe trauma, and severe sepsis. Study quality criteria, defined as a baseline quality of life assessment, the absence of major exclusion criteria, a description of nonresponders, and a comparison with a reference population were met in only four studies (8%). Results concerning the influence of severity of illness, comorbidity, preadmission quality of life, age, gender, or acquired complications were conflicting.

CONCLUSIONS

Quality of life differed on diagnostic category but, overall, critically ill patients had a lower quality of life than an age- and gender-matched population. A minority of studies met the predefined methodologic quality criteria. Results concerning the influence of the patients' characteristics and illnesses on long-term quality of life were conflicting.

Long-term effect of the ICU-diary concept on quality of life after critical illness

BACKGROUND

Critically ill patients often spend time in the intensive care unit (ICU) either unconscious or sedated. On recovery, they are often in a state of confusion with memory loss that may be associated with a longstanding reduction in health-related quality of life (QoL). We hypothesised that the ICU-diary concept could improve their QoL by filling in their memory gaps.

METHODS

A non-randomised, prospective study in a non-academic eight-bedded general ICU. A group of patients (n=38) were selected to receive the ICU-diary concept (keeping a diary with photos while on the ICU plus a follow-up meeting) when a long and complicated course was expected. Health-related QoL at 6, 12, 24 and 36 months was compared with a group that did not receive the ICU-diary (n=224). The Medical Outcomes Study 36-Item Short-Form (SF-36) was used to measure health-related QoL. Multiple regression models adjusted for age, sex, illness severity, pre-existing disease and diagnostic category was used to analyse the effects of the ICU-diary concept at 6 months, and changes over time were analysed using repeated measures MANOVA.

RESULTS

Crude and adjusted scores for two dimensions of SF-36 (general health and vitality) and the physical component summary score were significantly higher at 6 months in the ICU-diary group (P<0.05) and some of the effects remained during the 3-year follow-up period (P<0.05).

CONCLUSION

The ICU-diary concept was associated with improved health-related QoL during the 3-year follow-up period after a critical illness. The effect of this intervention needs to be confirmed in a larger randomised study.

Definition, risk factors and outcome of prolonged surgical intensive care unit stay

There is no generally accepted definition for a "prolonged surgical intensive care unit (SICU) stay". The aims of the current study were to: (1) define prolonged SICU stay; (2) identify risk factors of prolonged SICU stay; and (3) identify risk factors of hospital mortality in patients with a prolonged SICU stay. All SICU patients aged >16 years and with an intensive care unit (ICU) stay longer than three days without ICU readmission between 1 January 2004 and 30 November 2006 at the National Taiwan University Hospital were recruited to the study. A total of 2598 patients were recruited. ICU stay >16 days was defined as a prolonged SICU stay since rates of ICU mortality, hospital mortality and mortality one year after ICU discharge remained stationary after ICU stay was >16 days. A multivariate logistic regression model identified factors associated with a prolonged SICU stay, including age more than 70 years old, (odds ratio 1.587, 95% confidence interval 1.246 to 2.022), increasing pre-ICU hospital days (odds ratio 1.009, 95% confidence interval 1.003 to 1.015), admission from emergency (odds ratio 1.925, 95% confidence interval 1.455 to 2.548), use of mechanical circulation support (odds ratio 2.314, 95% confidence interval 1.458 to 3.674) and renal replacement therapy (odds ratio 5.140, 95% confidence interval 3.781 to 6.987). A multivariate logistic regression model identified factors associated with ICU mortality in patients with ICU stay >16 days, including renal replacement therapy (odds ratio 4.780, 95% confidence interval 2.687 to 8.504). An ICU stay >16 days could be used to define prolonged SICU stay when hospital and one-year mortality rates are considered. Prevention of organ failure requiring renal replacement therapy might prove a useful goal to avoid prolonged ICU stay and even hospital mortality.

[Characteristics and prognosis of patients with very long stay in an Intensive Care Unit]

OBJECTIVE

To describe the characteristics and prognostic factors of elderly patients hospitalized for > or = 30 days in an Intensive Care Unit (ICU).

DESIGN

Retrospective analysis of prospectively collected simple data over 6 consecutive years.

SETTING

Polyvalent ICU of the Insular University Hospital in the Canary Islands (Spain).

PATIENTS

Adult patients > or = 70 years who were hospitalized in the ICU for a period of 30 or more days.

PRIMARY VARIABLES OF INTEREST

Demographic data, clinical diagnosis on ICU admission, Apache II, days of renal replacement therapy (RRT), days of mechanical ventilation and the outcome of the survivors one year later were collected. Mortality at one year of the surviving patients was studied.

RESULTS

During the study period, 3,786 patients were admitted to the ICU. Of these, 853 (22.5%) patients were > or = 70 years old and only 42 (4.92%) of these patients remained in the ICU for > or = 30 days. We compared the latter with the > or = 70 year old patients whose stay in the ICU stay was < 30 days. No statistically significant differences in ICU mortality, Apache II, age, gender and the need for RRT were found. As independent variables associated with the long stay, the multivariate analysis showed only the days of mechanical ventilation (p < 0.05). The surviving patients (> or = 70 years old and whose stay in the ICU was > or = 30 days) were older and 21 (65.62%) were still alive one year later.

CONCLUSIONS

ICU mortality rates in elderly patients with a stay < or > or = 30 days in the ICU were comparable. Survival at one year of the > or = 70 year-old patients whose long-term intensive care unit stay was > or = 30 days was high. These results are sufficient in our unit to justify prolonged ICU care for elderly patients.

Effect of penetrating trunk trauma on the recovery of adult survivors: a pilot study

Gunshot and/or stab wounds to the trunk are injuries seen in South African hospitals. Patients are managed in the intensive care unit. Prolonged mechanical ventilation with immobilization results in some degree of muscle dysfunction. Our goal was to determine if patients recover adequately spontaneously following critical illness. No formal rehabilitation programmes exist in South Africa for these patients following discharge. A prospective, observational study was conducted. Patients were recruited from three ICUs in Johannesburg. Lung function tests, dynamometry, quality of life, 6-minute-walk, and oxygen uptake tests were performed over 6 months following discharge from the hospital. The control group consisted of existing data for healthy volunteers. Distance walked during 6-minute-walk test was significantly reduced for the study group compared to the control group (1 month [p = 0.00251]; 6 months [p = 0.0355]). At 1 month there was a significant reduction in quadriceps and triceps strength for the study group compared to the control group (p = 0.0089; p = 0.0246, respectively). Quadriceps strength remained significantly reduced for the study group (3 months [p = 0.0489]). No difference in muscle strength was detected between the groups at 6 months. Actual and predicted residual volumes differed significantly for the study group (1 month [p = 0.0034]; 6 months [p = 0.0157]). A trend of muscle weakness (to 3 months), poor exercise capacity, and abnormal lung volumes was identified. A formal rehabilitation programme may be needed to address these disabilities.

Resource use and outcome in critically ill patients with hematological malignancy: a retrospective cohort study

Introduction

The paucity of data on resource use in critically ill patients with hematological malignancy and on these patients' perceived poor outcome can lead to uncertainty over the extent to which intensive care treatment is appropriate. The aim of the present study was to assess the amount of intensive care resources needed for, and the effect of treatment of, hemato-oncological patients in the intensive care unit (ICU) in comparison with a nononcological patient population with a similar degree of organ dysfunction.

Methods

A retrospective cohort study of 101 ICU admissions of 84 consecutive hemato-oncological patients and 3,808 ICU admissions of 3,478 nononcological patients over a period of 4 years was performed.

Results

As assessed by Therapeutic Intervention Scoring System points, resource use was higher in hemato-oncological patients than in nononcological patients (median (interquartile range), 214 (102 to 642) versus 95 (54 to 224), P < 0.0001). Severity of disease at ICU admission was a less important predictor of ICU resource use than necessity for specific treatment modalities. Hemato-oncological patients and nononcological patients with similar admission Simplified Acute Physiology Score scores had the same ICU mortality. In hemato-oncological patients, improvement of organ function within the first 48 hours of the ICU stay was the best predictor of 28-day survival.

Conclusion

The presence of a hemato-oncological disease per se is associated with higher ICU resource use, but not with increased mortality. If withdrawal of treatment is considered, this decision should not be based on admission parameters but rather on the evolutional changes in organ dysfunctions.

Design and validation of a critical pathway for hospital management of patients with severe traumatic brain injury

BACKGROUND

Critical pathways for the management of patients with severe traumatic brain injury (STBI) may contribute to reducing the incidence of hospital complications, length of hospitalization stay, and cost of care. Such pathways have previously been developed for departments with significant resource availability. In Mexico, STBI is the most important cause of complications and length of stay in neurotrauma services at public hospitals. Although current treatment is designed basically in accordance with the Brain Trauma Foundation guidelines, shortfalls in the availability of local resources make it difficult to comply with these standards, and no critical pathway is available that accords with the resources of public hospitals. The purpose of the present study was to design and to validate a critical pathway for managing STBI patients that would be suitable for implementation in neurotrauma departments of middle-income level countries.

METHODS

The study comprised two phases: design (through literature review and design plan) and validation (content, construct, and appearance) of the critical pathway.

RESULTS

The validated critical pathway for managing STBI patients entails four sequential subprocesses summarizing the hospital's care procedures, and includes three components: (1) nodes and criteria (in some cases, indicators are also included); (2) health team members in charge of the patient; (3) maximum estimated time for compliance with recommendations.

CONCLUSIONS

This validated critical pathway is based on the current scientific evidence and accords with the availability of resources of middle-income countries.

Intensive care unit acquired infection has no impact on long-term survival or quality of life: a prospective cohort study

Introduction

The aim of this study was to evaluate the impact of intensive care unit (ICU)-acquired infection on long-term survival and quality of life.

Methods

Long-term survival was prospectively evaluated among hospital survivors who had stayed in a mixed, university-level ICU for longer than 48 hours during a 14-month study period during 2002 to 2003. Health-related quality of life was assessed using the five-dimensional EuroQol (EQ-5D) questionnaire in January 2005.

Results

Of the 272 hospital survivors, 83 (30.5%) died after discharge during the follow-up period. The median follow-up time after hospital discharge was 22 months. Among patients without infection on admission, long-term mortality did not differ between patients who developed and those who did not develop an ICU-acquired infection (21.7% versus 26.9%; P = 0.41). Also, among patients with infection on admission, there was no difference in long-term mortality between patients who developed a superimposed (35.1%) and those who did not develop a superimposed (27.6%) ICU-acquired infection (P = 0.40). The EQ-5D response rate was 75 %. The patients who developed an ICU-acquired infection had significantly more problems with self-care (50%) than did those without an ICU-acquired infection (32%; P = 0.004), whereas multivariate analysis did not show ICU-acquired infection to be a significant risk factor for diminished self-care (odds ratio = 1.71, 95% confidence interval = 0.65–4.54; P = 0.28). General health status did not differ between those with and those without an ICU-acquired infection, as measured using the EuroQol visual-analogue scale (mean ± standard deviation EuroQol visual-analogue scale value: 60.2 ± 21 in patients without ICU-acquired infection versus 60.6 ± 22 in those with ICU-acquired infection). The current general level of health compared with status before ICU admission did not differ between the groups either. Only 36% of those employed resumed their previous jobs.

Conclusion

ICU-acquired infection had no impact on long-term survival. The patients with ICU-acquired infection more frequently experienced problems with self-care than did those without ICU infection, but ICU-acquired infection was not a significant risk factor for diminished self-care in multivariate analysis.

Quality of life after stay in surgical intensive care unit

BACKGROUND

In addition to mortality, Health Related Quality of Life (HRQOL) has increasingly been claimed as an important outcome variable. The aim of this study was to assess HRQOL and independence in activities of daily living (ADL) six months after discharge from an Intensive Care Unit (ICU), and to study its determinants.

METHODS

All post-operative adult patients admitted to a surgical ICU between October 2004 and July 2005, were eligible for the study. The following variables were recorded on admission: age, gender, American Society of Anesthesiologists physical status (ASA-PS), type and magnitude of surgical procedure, ICU and hospital length of stay (LOS), mortality and Simplified Acute Physiology Score II (SAPS II). Six months after discharge, a Short Form-36 questionnaire (SF-36) and a questionnaire to assess dependency in ADL were sent to all survivors. Descriptive statistics was used to summarize data. Patient groups were compared using non-parametric tests. A logistic regression analysis was performed to identify covariate effects of each variable on dependency in personal and instrumental ADL, and for the change-in-health question of SF-36.

RESULTS

Out of 333 hospital survivors, 226 completed the questionnaires. Fifty-nine percent reported that their general level of health was better on the day they answered the questionnaire than 12 months earlier. Patients with greater co-morbidities (ASA-PS III/IV), had lower SF-36 scores in all domains and were more frequently dependent in instrumental and personal ADL. Logistic regression showed that SAPS II was associated with changes in general level of health (OR 1.06, 95%CI, 1.01-1.11, p = 0,016). Six months after ICU discharge, 60% and 34% of patients, respectively, were dependent in at least one activity in instrumental ADL (ADLI) and personal ADL (ADLP). ASA-PS (OR 3.00, 95%CI 1.31-6.87, p = 0.009) and age (OR 2.36, 95%CI, 1.04-5.34, p = 0.04) were associated with dependency in ADLI. For ADLP, only ASA-PS (OR 4.58, 95%CI, 1.68-12.46, p = 0.003) was associated with higher dependency.

CONCLUSION

ASA-PS, age, type of surgery, ICU LOS and SAPS II could be seen as determinants of HRQOL.

Health related quality of life six months following surgical treatment for secondary peritonitis--using the EQ-5D questionnaire

BACKGROUND

To compare health related quality of life (HR-QoL) in patients surgically treated for secondary peritonitis to that of a healthy population. And to prospectively identify factors associated with poorer (lower) HR-QoL.

DESIGN

A prospective cohort of secondary peritonitis patients was mailed the EQ-5D and EQ-VAS 6-months following initial laparotomy.

SETTING

Multicenter study in two academic and seven regional teaching hospitals.

PATIENTS

130 of the 155 eligible patients (84%) responded to the HR-QoL questionnaires.

RESULTS

HR-QoL was significantly worse on all dimensions in peritonitis patients than in a healthy reference population. Peritonitis characteristics at initial presentation were not associated with HR-QoL at six months. A more complicated course of the disease leading to longer hospitalization times and patients with an enterostomy had a negative impact on the mobility (p = 0.02), self-care (p < 0.001) and daily activities: (p = 0.01). In a multivariate analysis for the EQ-VAS every doubling of hospital stay decreases the EQ-VAS by 3.8 points (p = 0.015). Morbidity during the six-month follow-up was not found to be predictive for the EQ-5D or EQ-VAS.

CONCLUSION

Six months following initial surgery, patients with secondary peritonitis report more problems in HR-QoL than a healthy reference population. Unfavorable disease characteristics at initial presentation were not predictive for poorer HR-QoL, but a more complicated course of the disease was most predictive of HR-QoL at 6 months.

Injury in the Elderly and End-of-Life Decisions

The elderly constitute the fastest growing sector of the population of the United Stated and geriatric trauma patients are presenting for care with increasing frequency. These patients are challenging particularly because of their vulnerability to severe injury, limited physiologic response to stress, and frequent presence of comorbid medical conditions complicating care. Many elderly trauma victims require prolonged intensive care and some fail to improve or succumb despite the best efforts because of the extent of their injuries and their underlying disease. These patients may present profound ethical challenges for trauma surgeons as the goals of care shift from salvage to end-of-life care.

Measurement properties of the short form 36 and health-related quality of life after intensive care in Morocco

BACKGROUND

Intensive care patients have a health-related quality of life (HRQL) that differs from the normal population. The aim of this study was to evaluate the measurement properties of the Arabic version of the short form (SF)-36 and study the HRQL determinants in adult patients 3 months after discharge from an intensive care unit (ICU).

METHODS

A prospective cohort study after ICU discharge. At 3-month follow up, the SF-36 was administered in consultation or by telephone. Multitrait scaling analysis was used to confirm the hypothesized scale structure of the SF-36. Reliability was tested using (i) measuring internal consistency; and (ii) the test-retest reliability assessed using an intraclass correlation coefficient. Construct validity was tested by known-groups comparison using one-way analysis of variance (ANOVA) and analysis of covariance (ANCOVA).

RESULTS

A total of 145 survivors answered the SF-36. Item internal convergency was higher than 0.40 (0.77-0.99; 100% scaling success) and item discriminant validity was perfect (100% scaling success) except for physical functioning (81% scaling success). Cronbach's alpha exceeded 0.70 in all eight scales (0.84-0.99). Test-retest reliability conducted in 73 patients was above 0.80. Acceptability to patients appeared reasonable although considerable interview time was required to administer the SF-36. Construct validity was confirmed by lower scores being reported by women, older age and a high level of comorbidities groups. When adjusted for background data, ICU variables were not associated with the SF-36 scores.

CONCLUSIONS

The Arabic version of the SF-36 appears to be a robust tool in ICU. Background variables are the only significant determinants of HRQL 3 months after medical ICU discharge.

Outcome and functional capacity after prolonged intensive care unit stay

BACKGROUND

An important proportion of critically ill patients who survives their acute illness remains in a critical state requiring intensive care management for weeks to months. Nevertheless, data on risk factors for in-hospital mortality and especially for long-term mortality and functional capacity are scarce. This study investigated outcome and prognostic factors in long-term critically ill patients.

METHODS

This retrospective observational cohort study was performed at our mixed adult 8-bed cardiologic ICU at a 2200-bed University Hospital. Patient data from our local database connected to an Austrian multicenter program for quality assurance in intensive care were analyzed. Data were collected between March 1(st), 1998 and December 31(st), 2003. Patients with an ICU stay > or =30 days formed the long-term study group. Morbidity and functional capacity were assessed using the Barthel mobility index in telephone interviews.

RESULTS

Patients spending > or =30 days in the ICU numbered 135 (10%) and occupied 5962 bed-days, representing 40.9% of the total bed-days. Compared with patients with an ICU stay <30 days, patients in the long-term group had a significantly higher SAPS II score during the first 24 hours after ICU admission (54 [IQR 41-65] vs. 38 [IQR 27-56], p < 0.001). There was a trend towards male preponderance in the long-term group (98/135 [82.6%] vs. 782/1215 [64.4%], p = 0.05). Differences in ICU and in-hospital mortality were not significant (28/135 (20.7%) vs. 295/1215 (24.3%), p = 0.620 and 46/135 [34.1%] vs. 360/1215 [29.6%], p = 0.285, respectively). After 12 and 48 months, the overall cumulative rates of death in hospital survivors were 14% and 26%, respectively in the short-term ICU group and 31% and 61% in the long-term group. A log-rank test revealed a significantly higher probability of survival in the short-term group after hospital discharge (log rank = 34.3, p < 0.001). Multivariate analysis of hospital survivors and non-survivors in the long-term group showed that the need for renal replacement therapy during the ICU stay was the sole independent predictor for in-hospital death and death within 1 year after ICU discharge (OR = 2.88; 95%CI 1.12-7.41, p = 0.028 and OR = 3.66, 95%CI 1.36-9.83, p = 0.01, respectively). In 28/31 long-term survivors (90%) in the long-term ICU group, the Barthel index indicated no or only moderate disability during daily activities.

CONCLUSION

Hospital mortality rates in critically ill patients with a stay <30 or > or =30 days were comparable. The necessity for renal replacement therapy was the sole independent predictor for in-hospital and 1-year mortality in long-term ICU patients. Critically ill patients with a stay > or =30 days have a high and ongoing risk of death after hospital discharge; however, a substantial number of these patients are long-term survivors with no or only moderate disability during daily activities.