The Association between Patient Health Status and Surrogate Decision Maker Post-Traumatic Stress Disorder Symptoms in Chronic Critical Illness

The Tri-Steps Model of Critical Conditions in Intensive Care: Introducing a New Paradigm for Chronic Critical Illness

Background: The prevailing model for understanding chronic critical illness is a biphasic model, suggesting phases of acute and chronic critical conditions. A major challenge within this model is the difficulty in determining the timing of the process chronicity. It is likely that the triad of symptoms (inflammation, catabolism, and immunosuppression [ICIS]) could be associated with this particular point. We aimed to explore the impact of the symptom triad (inflammation, catabolism, immunosuppression) on the outcomes of patients hospitalized in intensive care units (ICUs). Methods: The eICU-CRD database with 200,859 ICU admissions was analyzed. Adult patients with the ICIS triad, identified by elevated CRP (>20 mg/L), reduced albumin (<30 g/L), and low lymphocyte counts (<0.8 × 109/L), were included. The cumulative risk of developing ICIS was assessed using the Nelson-Aalen estimator. Results: This retrospective cohort study included 894 patients (485 males, 54%), with 60 (6.7%) developing ICIS. The cumulative risk of ICIS by day 21 was 22.5%, with incidence peaks on days 2-3 and 10-12 after ICU admission. Patients with the ICIS triad had a 2.5-fold higher mortality risk (p = 0.009) and double the likelihood of using vasopressors (p = 0.008). The triad onset day did not significantly affect mortality (p = 0.104). Patients with ICIS also experienced extended hospital (p = 0.041) and ICU stays (p < 0.001). Conclusions: The symptom triad (inflammation, catabolism, immunosuppression) during hospitalization increases mortality risk by 2.5 times (p = 0.009) and reflects the chronicity of the critical condition. Identifying two incidence peaks allows the proposal of a new Tri-steps model of chronic critical illness with acute, extended, and chronic phases.

An environmental scan of online resources for informal family caregivers of ICU survivors

PURPOSE

To collate a comprehensive repository of online resources for family caregivers of intensive care survivors to inform a recovery website and digital peer support programme.

MATERIALS AND METHODS

To identify resources, we conducted an environmental scan using processes recommended by the Canadian Agency for Drugs and Technologies in Health and guided by clinical experts, former patients, and family members. We searched internet sources, professional society websites, social media, and contacted our professional networks.

RESULTS

Through expert consultation we identified 16 information categories and found 301 online resources. Five categories with the most resources were: how to look after yourself/recognise anxiety or post-traumatic stress/getting mental health support (n = 63); information specific to conditions necessitating ICU admission (n = 49); multiple category resources (n = 46); symptoms of post-intensive care syndrome (n = 44); stories of lived experience (n = 23). Five categories with the least resources were physical, emotional and cognitive symptoms of post-intensive care syndrome-family (n = 1); interacting with primary care (n = 2); medical deterioration (how to recognise/what to do) (n = 2); driving and accessing the community (n = 3); end-of-life and bereavement (n = 5). Of these resources, we included 45 on our recovery website.

CONCLUSION

This environmental scan identifies multiple resources addressing informational needs of family caregivers and highlights areas for resource development.

Being devastated by critical illness journey in the family: A grounded theory approach of post-intensive care syndrome-family

OBJECTIVES

This study aimed to explore the meaning and structure of postintensive care syndrome experienced by families of critically ill patients.

METHODS

This qualitative study applied the constructivist grounded theory approach and conducted one or two interviews with eight participants with postintensive care syndrome-family for a total of 12 interviews. The contents of the interviews were analysed through line-by-line coding, focused coding, and categorisation. Data collection and analysis were iterative, to enable continuous comparative analysis.

FINDINGS

The core category of postintensive care syndrome experienced by families was 'being devastated by the critical illness journey in the family' and comprised the interactions of four categories: 'overwhelming intensive care experience', 'taking responsibility for the recovery trajectory of critical illness', 'life devastated by the trauma of intensive care and family caregiving', and 'balancing and compromising'.

CONCLUSION

Based on this grounded theory approach, postintensive care syndrome experienced by families is a complex and ongoing phenomenon that arises from the recovery trajectory of a critical illness. It involves mental, physical, social and familial aspects, particularly the impact on the patient's family.

IMPLICATIONS FOR CLINICAL PRACTICE

The findings can guide critical care nurses to understand postintensive care syndrome experienced by families in providing patient or family-centred care. To improve the long-term outcomes and quality of life for families, it is necessary to assess their unique needs within the continuum of post-intensive care syndrome experienced by the family and to propose interventions to satisfy those needs.

Surrogates of Patients With Severe Acute Brain Injury Experience Persistent Anxiety and Depression Over the 6 Months After ICU Admission

CONTEXT

Severe Acute Brain Injury (SABI) is neurologically devastating, and surrogates for these patients may struggle with particularly complex decisions due to substantial prognostic uncertainty.

OBJECTIVES

To compare anxiety and depression symptoms over time between SABI surrogates and non-SABI surrogates for patients requiring prolonged mechanical ventilation (PMV).

METHODS

We conducted a secondary analysis of the data from a multicenter randomized trial of a decision aid intervention for surrogates of adults experiencing PMV. Eligible patients were enrolled from medical, surgical, trauma, cardiac, and neurologic intensive care units (ICUs). ICU admitting diagnoses were used to identify patients experiencing SABI. We compared anxiety and depression symptoms as measured by the Hospital Anxiety and Depression Scale score 6 months after trial enrollment between surrogates of patients with SABI and surrogates of patients experiencing PMV for other reasons.

RESULTS

Our analysis included 206 patients, 60 (29%) with SABI and 146 (71%) without SABI, and their primary surrogate decision makers. After adjusting for potential confounders including surrogate demographics, surrogate financial distress, patient severity of illness baseline GCS, and patient health status at 6 months, we found that surrogates of patients experiencing SABI had higher symptoms of anxiety and depression than surrogates of non-SABI patients (adjusted mean difference 3.6, 95% CI 1.2-6.0).

CONCLUSION

Surrogates of PMV patients with SABI experience persistently elevated anxiety and depression symptoms over 6 months compared to surrogates of PMV patients without SABI. Further work is needed to understand contributors to prolonged distress in this higher risk population.

The Experiences and Needs of Families of Comatose Patients After Cardiac Arrest and Severe Neurotrauma: The Perspectives of National Key Stakeholders During a National Institutes of Health–Funded Workshop

Severe acute brain injury (SABI) from cardiac arrest and traumatic brain injury happens suddenly and unexpectedly, carrying high potential for lifelong disability with substantial prognostic uncertainty. Comprehensive assessments of family experiences and support needs after SABI are lacking. Our objective is to elicit “on-the-ground” perspectives about the experiences and needs of families of patients with SABI.