Recovery following discharge from intensive care: What do patients think is helpful and what services are missing?

BACKGROUND

Recovery following critical illness is complex due to the many challenges patients face which influence their long-term outcomes. We explored patients' views about facilitators of recovery after critical illness which could be used to inform the components and timing of specific rehabilitation interventions.

AIMS

To explore the views of patients after discharge from an intensive care unit (ICU) about their recovery and factors that facilitated recovery, and to determine additional services that patients felt were missing during their recovery.

METHODS

Qualitative study involving individual face-to-face semi-structured interviews at six months (n = 11) and twelve months (n = 10). Written, informed consent was obtained. [Ethics approval 17/NI/0115]. Interviews were audiotaped, transcribed and analysed using template analysis.

FINDINGS

Template analysis revealed four core themes: (1) Physical activity and function; (2) Recovery of cognitive and emotional function; (3) Facilitators to recovery; and (4) Gaps in healthcare services.

CONCLUSION

Patient reported facilitators to recovery include support and guidance from others and self-motivation and goal setting, equipment for mobility and use of technology. Barriers include a lack of follow up services, exercise rehabilitation, peer support and personal feedback. Patients perceived that access to specific healthcare services was fragmented and where services were unavailable this contributed to slower or poorer quality of recovery. ICU patient recover could be facilitated by a comprehensive rehabilitation intervention that includes patient-directed strategies and health care services.

Early mobilization of critically ill ICU patients: A survey of knowledge, perceptions, and practices of Malaysian physiotherapists

INTRODUCTION

Early mobilization and rehabilitation of critically ill patients in the Intensive care unit (ICU) is a topic of growing interest. Current evidence suggests that early mobilization is safe, feasible, and effective at reducing the incidence of ICU-acquired weakness. However, early mobilization is still not the standard of care in most ICUs worldwide. The aim of the study was to determine the level of knowledge, perceptions, and practice among ICU physiotherapists of early mobilization in critically ill ICU patients in Malaysia.

MATERIALS AND METHODS

A cross-sectional study was undertaken in 45 public, teaching, and private hospitals in Malaysia that provide ≥ 10 beds in their ICUs. Knowledge, perceived barriers, facilitators, and practice of early mobilization were assessed using a previously validated mobility survey questionnaire.

RESULTS

Only 35% of ICU physiotherapists reported receiving training/courses on early mobilization in the ICU. 100 (86%) physiotherapists underestimated the incidence of ICU-acquired weakness, and 88 (75%) were unfamiliar with the current literature on early mobilization in the ICU. The need for physician orders before mobilization, medical instability, excessive sedation, and risk of dislodgement of devices or lines were the most common barriers to early mobilization. Nearly half (49 [42%]) of the respondents reported physiotherapist as early mobilization clinical champion in their setting, but the most common physiotherapy treatment techniques in the ICU reported by the respondents' were still chest physiotherapy, range of motion exercises, and bed mobility.

CONCLUSION

We observed strong enthusiasm for early mobilization among Malaysian physiotherapists. Most respondents believed that early mobilization is important and beneficial to ICU patients. However, there is still a big gap in knowledge and training of early mobilization in ICU patients among Malaysian physiotherapists.

Cognitive impairment in critically ill patients and former critically ill patients: A concept analysis

OBJECTIVES

This concept analysis aimed to clarify the meaning of the concept of cognitive impairment in critically ill patients throughout the trajectory of their rehabilitation during and after an intensive care unit admission.

REVIEW METHODS USED

This study used concept analysis based on Rodgers' evolutionary method.

DATA SOURCES

A systematic search was conducted in Cumulative Index to Nursing and Allied Health Literature, Public MEDLINE, and American Psychological Associations PsycINFO. The web was searched for grey literature.

REVIEW METHODS

Overall search terms used were "patients with cognitive impairments" AND "intensive care unit". Literature published between 2008 and 2022 was included and screened by title and abstract using systematic review software. The descriptive analysis focussed on surrogate terms/related concepts, attributes, and contextual basis.

RESULTS

Thirty studies were included, representing variability in study design and country of origin. The analysis uncovered descriptions of the general terminology and the temporal trajectory of the concept, spanning from the acute phase to a long-term perspective. Attributes of the concept were described as delirium and domains of cognition. Antecedents were juxtaposed to risk factors, which were multifactorial. Consequences of cognitive impairment related to patients' quality of life, such as a decline in their ability to function independently, return to work, and manage everyday life. Also, cognitive impairment was identified as a significant public health problem.

CONCLUSION

Cognitive impairment is a complex concept with many surrogate and related terms. Furthermore, the concept is inextricably intertwined with the concepts of delirium and post-intensive care syndrome. Cognitive impairment may manifest as symptoms that can be challenging to identify and assess due to limitations in current screening tools and the absence of a consensus on timing. In relation to assessment and preventive strategies, the findings underline the need to distinguish between acute and long-term cognitive impairment.

REGISTRATION

There is no study registration number.

Physical rehabilitation in Brazilian pediatric intensive care units: a multicenter point prevalence study

OBJECTIVE

To determine the prevalence and factors associated with the physical rehabilitation of critically ill children in Brazilian pediatric intensive care units.

METHODS

A 2-day, cross-sectional, multicenter point prevalence study comprising 27 pediatric intensive care units (out of 738) was conducted in Brazil in April and June 2019. This Brazilian study was part of a large multinational study called Prevalence of Acute Rehabilitation for Kids in the PICU (PARK-PICU). The primary outcome was the prevalence of mobility provided by physical therapy or occupational therapy. Clinical data on patient mobility, potential mobility safety events, and mobilization barriers were prospectively collected in patients admitted for ≥ 72 hours.

RESULTS

Children under the age of 3 years comprised 68% of the patient population. The prevalence of therapist-provided mobility was 74%, or 277 out of the 375 patient-days. Out-of-bed mobility was most positively associated with family presence (adjusted odds ratios 3.31;95%CI 1.70 - 6.43) and most negatively associated with arterial lines (adjusted odds ratios 0.16; 95%CI 0.05 - 0.57). Barriers to mobilization were reported on 27% of patient-days, the most common being lack of physician order (n = 18). Potential safety events occurred in 3% of all mobilization events.

CONCLUSION

Therapist-provided mobility in Brazilian pediatric intensive care units is frequent. Family presence was high and positively associated with out-of-bed mobility. The presence of physiotherapists 24 hours a day in Brazilian pediatric intensive care units may have a substantial impact on the mobilization of critically ill children.

Illness Weakness, Polyneuropathy and Myopathy: Diagnosis, treatment, and long-term outcomes

BACKGROUND

Severe weakness associated with critical illness (CIW) is common. This narrative review summarizes the latest scientific insights and proposes a guide for clinicians to optimize the diagnosis and management of the CIW during the various stages of the disease from the ICU to the community stage.

MAIN BODY

CIW arises as diffuse, symmetrical weakness after ICU admission, which is an important differentiating factor from other diseases causing non-symmetrical muscle weakness or paralysis. In patients with adequate cognitive function, CIW can be easily diagnosed at the bedside using manual muscle testing, which should be routinely conducted until ICU discharge. In patients with delirium or coma or those with prolonged, severe weakness, specific neurophysiological investigations and, in selected cases, muscle biopsy are recommended. With these exams, CIW can be differentiated into critical illness polyneuropathy or myopathy, which often coexist. On the general ward, CIW is seen in patients with prolonged previous ICU treatment, or in those developing a new sepsis. Respiratory muscle weakness can cause neuromuscular respiratory failure, which needs prompt recognition and rapid treatment to avoid life-threatening situations. Active rehabilitation should be reassessed and tailored to the new patient's condition to reduce the risk of disease progression. CIW is associated with long-term physical, cognitive and mental impairments, which emphasizes the need for a multidisciplinary model of care. Follow-up clinics for patients surviving critical illness may serve this purpose by providing direct clinical support to patients, managing referrals to other specialists and general practitioners, and serving as a platform for research to describe the natural history of post-intensive care syndrome and to identify new therapeutic interventions. This surveillance should include an assessment of the activities of daily living, mood, and functional mobility. Finally, nutritional status should be longitudinally assessed in all ICU survivors and incorporated into a patient-centered nutritional approach guided by a dietician.

CONCLUSIONS

Early ICU mobilization combined with the best evidence-based ICU practices can effectively reduce short-term weakness. Multi-professional collaborations are needed to guarantee a multi-dimensional evaluation and unitary community care programs for survivors of critical illnesses.

Responsiveness of Critically Ill Adults With Multimorbidity to Rehabilitation Interventions: A Patient-Level Meta-Analysis Using Individual Pooled Data From Four Randomized Trials

OBJECTIVE

To explore if patient characteristics (pre-existing comorbidity, age, sex, and illness severity) modify the effect of physical rehabilitation (intervention vs control) for the coprimary outcomes health-related quality of life (HRQoL) and objective physical performance using pooled individual patient data from randomized controlled trials (RCTs).

DATA SOURCES

Data of individual patients from four critical care physical rehabilitation RCTs.

STUDY SELECTION

Eligible trials were identified from a published systematic review.

DATA EXTRACTION

Data sharing agreements were executed permitting transfer of anonymized data of individual patients from four trials to form one large, combined dataset. The pooled trial data were analyzed with linear mixed models fitted with fixed effects for treatment group, time, and trial.

DATA SYNTHESIS

Four trials contributed data resulting in a combined total of 810 patients (intervention n = 403, control n = 407). After receiving trial rehabilitation interventions, patients with two or more comorbidities had HRQoL scores that were significantly higher and exceeded the minimal important difference at 3 and 6 months compared with the similarly comorbid control group (based on the Physical Component Summary score (Wald test p = 0.041). Patients with one or no comorbidities who received intervention had no HRQoL outcome differences at 3 and 6 months when compared with similarly comorbid control patients. No patient characteristic modified the physical performance outcome in patients who received physical rehabilitation.

CONCLUSIONS

The identification of a target group with two or more comorbidities who derived benefits from the trial interventions is an important finding and provides direction for future investigations into the effect of rehabilitation. The multimorbid post-ICU population may be a select population for future prospective investigations into the effect of physical rehabilitation.

Effects of early cognitive rehabilitation training on cognitive function and quality of life in critically ill patients with cognitive impairment: A randomised controlled trial

BACKGROUND

Patients often develop cognitive dysfunction during admission to the ICU and after being transferred out of the ICU, which leads to physical disorders, sleep disorders, and psychological stress.Cognitive rehabilitation training can significantly improve patients' planning, decision-making ability, and executive function.

OBJECTIVE

The aim of this study was to explore the role of early cognitive rehabilitation training in improving cognitive impairment in critically ill patients.

METHODS

This study was a prospective, randomised, controlled clinical trial conducted from January 2017 to June 2021. Critically ill patients with cognitive impairment admitted to the Department of Intensive Care Medicine of The Third Hospital of Mianyang were randomly divided into the control (n = 68) and intervention groups (n = 68). Cognitive rehabilitation training (including digital operating system training, music therapy, aerobic training, and mental health intervention) was applied to the patients in the intervention group for 6 months, while the control group did not receive any cognitive intervention. Before 3 and 6 months after enrolment, the Montreal Cognitive Assessment and the 36-Item Short Form Health Survey Scale were used to evaluate cognitive function and quality of life, respectively, in both groups.

RESULTS

A total of 136 critical patients were included in the final analysis. There were no significant differences in sex, age, years of education, complications, intensive care unit hospitalisation time, mechanical ventilation time, or the total score of the Montreal Cognitive Assessment scale when transferred out of the intensive care unit in 24 hours between the two groups. Six months later, the results of the follow-up showed that the cognitive function score in the intervention group was significantly higher than that in the control group (26.69 ± 2.49 vs. 23.03 ± 3.79). The analysis of quality of life showed that the scores in all areas in the intervention group improved. There were significant differences in physical functioning (69.02 ± 8.14 vs. 63.38 ± 11.94), role physical (62.02 ± 12.18 vs. 58.09 ± 8.83), general health (46.00 ± 15.21 vs. 40.38 ± 13.77), vitality (61.00 ± 11.01 vs. 54.38 ± 13.80), social functioning (70.00 ± 10.29 vs. 64.41 ± 13.61), role emotional (78.00 ± 8.00 vs. 72.15 ± 12.18), and mental health (71.00 ± 12.33 vs. 55.37 ± 10.76) between the two groups (P < 0.05).

CONCLUSION

Early cognitive rehabilitation training can improve cognitive impairment in critically ill patients and their quality of life.

Structured Mobilization for Critically Ill Patients: A Pragmatic Cluster-randomized Trial

Rationale: Small trials and professional recommendations support mobilization interventions to improve recovery among critically ill patients, but their real-world effectiveness is unknown. Objective: To evaluate a low-cost, multifaceted mobilization intervention. Methods: We conducted a stepped-wedge cluster-randomized trial across 12 ICUs with diverse case mixes. The primary and secondary samples included patients mechanically ventilated for ⩾48 hours who were ambulatory before admission, and all patients with ICU stays ⩾48 hours, respectively. The mobilization intervention included 1) designation and posting of daily mobilization goals; 2) interprofessional closed-loop communication coordinated by each ICU's facilitator; and 3) performance feedback. Measurements and Main Results: From March 4, 2019 through March 15, 2020, 848 and 1,069 patients were enrolled in the usual care and intervention phases in the primary sample, respectively. The intervention did not increase the primary outcome, patient's maximal Intensive Care Mobility Scale (range, 0-10) score within 48 hours before ICU discharge (estimated mean difference, 0.16; 95% confidence interval, -0.31 to 0.63; P = 0.51). More patients in the intervention (37.2%) than usual care (30.7%) groups achieved the prespecified secondary outcome of ability to stand before ICU discharge (odds ratio, 1.48; 95% confidence interval, 1.02 to 2.15; P = 0.04). Similar results were observed among the 7,115 patients in the secondary sample. The percentage of days on which patients received physical therapy mediated 90.1% of the intervention effect on standing. ICU mortality (31.5% vs. 29.0%), falls (0.7% vs. 0.4%), and unplanned extubations (2.0% vs. 1.8%) were similar between groups (all P > 0.3). Conclusions: A low-cost, multifaceted mobilization intervention did not improve overall mobility but improved patients' odds of standing and was safe. Clinical trial registered with www.clinicaltrials.gov (NCT03863470).

Physical therapy and nutrition therapy: synergistic, antagonistic, or independent interventions?

PURPOSE OF REVIEW

Physical therapy and nutrition therapy have predominantly been studied separately in the critically ill, however in clinical practice are often delivered in combination. It is important to understand how these interventions interact. This review will summarize the current science - where they are potentially synergistic, antagonistic, or independent interventions.

RECENT FINDINGS

Only six studies were identified within the ICU setting that combined physical therapy and nutrition therapy. The majority of these were randomized controlled trials with modest sample sizes. There was an indication of benefit in the preservation of femoral muscle mass and short-term physical quality of life - particularly with high-protein delivery and resistance exercise, in patients who were predominantly mechanically ventilated patients, with an ICU length of stay of approximately 4-7 days (varied across studies). Although these benefits did not extend to other outcomes such as reduced length of ventilation, ICU or hospital admission. No recent trials were identified that combined physical therapy and nutrition therapy in post-ICU settings and is an area that warrants investigation.

SUMMARY

The combination of physical therapy and nutrition therapy might be synergistic when evaluated within the ICU setting. However, more careful work is required to understand the physiological challenges in the delivery of these interventions. Combining these interventions in post-ICU settings is currently under-investigated, but may be important to understand any potential benefits to patient longitudinal recovery.

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.

Early Rehabilitation Interventions and Physical Therapy in Adults Who Were Critically Ill with COVID−19 Pneumonia: A Retrospective Observational Study

Objective

The primary objective of this observational study was to analyze the time to the first edge-of-bed (EOB) mobilization in adults who were critically ill with severe versus non-severe COVID-19 pneumonia. Secondary objectives included the description of early rehabilitation interventions and physical therapy delivery.

Methods

All adults with laboratory-confirmed COVID-19 requiring intensive care unit admission for ≥72 hours were included and divided according to their lowest PaO2/FiO2 ratio into severe (≤ 100 mmHg) or non-severe (&gt; 100 mmHg) COVID-19 pneumonia. Early rehabilitation interventions consisted of in-bed activities, edge-of-bed or out-of-bed mobilizations, standing, and walking. The Kaplan–Meier estimate and logistic regression were used to investigate the primary outcome time-to-EOB and factors associated with delayed mobilization.

Results

Among the 168 patients included in the study (mean age = 63 y [SD = 12 y]; Sequential Organ Failure Assessment [SOFA] = 11 [IQR 9–14]), 77 (46%) were classified as non-severe and 91 (54%) were classified as severe COVID-19 pneumonia. Median time-to-EOB was 3.9 days (95% CI = 2.3–5.5) with significant differences between subgroups (non-severe = 2.5 days [95% CI = 1.8–3.5]; severe = 7.2 days [95% CI = 5.7–8.8]). Extracorporeal membrane oxygenation (ECMO) use and high SOFA scores (adjusted effect = 13.7 days [95% CI = 10.1–17.4] and 0.3 days [95% CI = 0.1–0.6]) were significantly associated with delayed EOB mobilization. Physical therapy started within a median of 1.0 days (95% CI = 0.9–1.2) without subgroup differences.

Conclusions

This study shows that early rehabilitation and physical therapy within the recommended 72 hours during the COVID-19 pandemic could be maintained regardless of disease severity. In this cohort, the median time-to-EOB was fewer than 4 days, with disease severity and advanced organ support significantly delaying the time-to-EOB.

Impact

Early rehabilitation in the intensive care unit could be sustained in adults who are critically ill with COVID-19 pneumonia and can be implemented with existing protocols. Screening based on PaO2/FiO2 ratio might reveal patients at risk and increased need for physical therapy.

Interviews with primary care physicians identify unmet transition needs after ICU

AIM

We sought to explore unmet needs in transitions of care for critical illness survivors that concern primary care physicians.

FINDINGS

Semi-structured interviews with primary care physicians identified three categories of concerns about unmet transition needs after patients' ICU stays: patients' understanding of their ICU stay and potential complications, treatments or support needs not covered by insurance, and starting and maintaining needed rehabilitation and assistance across transitions of care.

CONCLUSION

Given current constraints of access to coordinated post-ICU care, efforts to identify and address the post-hospitalization needs of critical illness survivors may be improved through coordinated work across the health system.

The impact of physical medicine and rehabilitation consultation on clinical outcomes in the surgical intensive care unit: A prospective observational cohort study

The impact of a physical medicine and rehabilitation (PM&R) consultation on clinical outcomes in critically ill surgical patients remains unclear. The aim of this study is to examine whether the patients who received PM&R consultation will demonstrate better clinical outcomes in terms of the differences in clinical outcomes including muscle mass and strength, intensive care unit (ICU) length of stay (LOS) and functional outcomes between the PM&R consultation and no PM&R consultation and between early PM&R consultation and late PM&R consultation in critically ill surgical patients.A prospective observational cohort study was undergone in 65-year-old or older patients who were admitted > 24 hours in the surgical intensive care unit (SICU) in a tertiary care hospital. Data collection included patients' characteristic, muscle mass and muscle strength, and clinical outcomes.Ninety surgical patients were enrolled and PM&R was consulted in 37 patients (36.7%). There was no significant difference in muscle mass and function between consulted and no consulted groups. PM&R consulted group showed worse in clinical outcomes including functional outcomes at hospital discharge, longer duration of mechanical ventilation, ICU, and hospital LOS as compared with no PM&R consulted group. The median time of rehabilitation consultation was 6 days and there were no significant differences in clinical outcomes between early (≤ 6 days) and late (> 6 days) consultation.PM&R consultation did not improve muscle mass, functional outcomes at hospital discharge, and ICU LOS in critically ill surgical patients. The key to success might include the PM&R consultation with both intensified physical therapy and early start of mobilization or the rigid mobilization protocol.

Association of Social Isolation With Disability Burden and 1-Year Mortality Among Older Adults With Critical Illness

Importance

Disability and mortality are common among older adults with critical illness. Older adults who are socially isolated may be more vulnerable to adverse outcomes for various reasons, including fewer supports to access services needed for optimal recovery; however, whether social isolation is associated with post-intensive care unit (ICU) disability and mortality is not known.

Objectives

To evaluate whether social isolation is associated with disability and with 1-year mortality after critical illness.

Design, Setting, and Participants

This observational cohort study included community-dwelling older adults who participated in the National Health and Aging Trends Study (NHATS) from May 2011 through November 2018. Hospitalization data were collected through 2017 and interview data through 2018. Data analysis was conducted from February 2020 through February 2021. The mortality sample included 997 ICU admissions of 1 day or longer, which represented 5 705 675 survey-weighted ICU hospitalizations. Of these, 648 ICU stays, representing 3 821 611 ICU hospitalizations, were eligible for the primary outcome of post-ICU disability.

Exposures

Social isolation from the NHATS survey response in the year most closely preceding ICU admission, which was assessed using a validated measure of social connectedness with partners, families, and friends as well as participation in valued life activities (range 0-6; higher scores indicate more isolation).

Main Outcomes and Measures

The primary outcome was the count of disability assessed during the first interview following hospital discharge. The secondary outcome was time to death within 1 year of hospital admission.

Results

A total of 997 participants were in the mortality cohort (511 women [51%]; 45 Hispanic [5%], 682 non-Hispanic White [69%], and 228 non-Hispanic Black individuals [23%]) and 648 in the disability cohort (331 women [51%]; 29 Hispanic [5%], 457 non-Hispanic White [71%], and 134 non-Hispanic Black individuals [21%]). The median (interquartile range [IQR]) age was 81 (75.5-86.0) years (range, 66-102 years), the median (IQR) preadmission disability count was 0 (0-1), and the median (IQR) social isolation score was 3 (2-4). After adjustment for demographic characteristics and illness severity, each 1-point increase in the social isolation score (from 0-6) was associated with a 7% greater disability count (adjusted rate ratio, 1.07; 95% CI, 1.01-1.15) and a 14% increase in 1-year mortality risk (adjusted hazard ratio, 1.14; 95% CI, 1.03-1.25).

Conclusions and Relevance

In this cohort study, social isolation before an ICU hospitalization was associated with greater disability burden and higher mortality in the year following critical illness. The study findings suggest a need to develop social isolation screening and intervention frameworks for older adults with critical illness.

Activity Levels in Survivors of the Intensive Care Unit

OBJECTIVE

Limited data exist on the quantification of activity levels and functional status in critically ill patients as they transition from the intensive care unit (ICU) to the wards and, subsequently, back into the community. The physical activity of critically ill patients from their ICU stay until 7 days after hospital discharge was characterized, as well as correlate physical activity levels with an objective measure of physical function.

METHODS

This prospective observational study of previously independent adults aged 55 or older, undergoing mechanical ventilation for up to 7 days, recruited participants at the time of spontaneous breathing trials or less than 24 hours after extubation. Participants received an accelerometer at enrollment to wear until 1 week after discharge.

RESULTS

Twenty-two participants received accelerometers; 15 were suitable for analysis. Participants had a mean (SD) age of 68 (9.6) years; 47% were female. Mean step counts were 95 (95% CI = 15-173) in the 3 days before ICU discharge, 257 (95% CI = 114-400) before hospital discharge, 1223 (95% CI = 376-2070) in the first 3 days at home, and 1278 (95% CI = 349-2207) between day 4 and 6 post-hospital discharge. Physical activity was significantly higher post- compared with pre-hospital discharge. Short Physical Performance Battery scores were poor at ICU and hospital discharge; however, they correlated moderately with physical activity levels immediately upon return home.

CONCLUSIONS

Physical activity remained low as survivors of critical illness transitioned from ICU to hospital wards, but significantly increased upon return to the community. Despite poor Short Physical Performance Battery scores at both ICU and hospital discharge, participants were significantly more active immediately after discharge than in their last 3 days of hospitalization. This may represent rapid functional improvement or, conversely, constrained physical activity in hospital.

IMPACT

This study highlights the need for further evaluation of physical activity constraints in hospital and ways to augment physical activity and function upon discharge.

LAY SUMMARY

Physical activity (step counts) increased modestly as survivors of critical illness transitioned from ICU to hospital wards, but significantly increased upon return to the community. This study highlights the need for further evaluation of physical activity constraints in the hospital setting and ways to augment physical activity and function postdischarge.

Feasibility of a home-based interdisciplinary rehabilitation program for patients with Post-Intensive Care Syndrome: the REACH study

BACKGROUND

Survivors of critical illness experience long-term functional challenges, which are complex, heterogeneous, and multifactorial in nature. Although the importance of rehabilitation interventions after intensive care unit (ICU) discharge is universally recognized, evidence on feasibility and effectiveness of home-based rehabilitation programs is scarce and ambiguous. This study investigates the feasibility of an interdisciplinary rehabilitation program designed for patients with Post-Intensive Care Syndrome (PICS) who are discharged home.

METHODS

A mixed method, non-randomized, prospective pilot feasibility study was performed with a 6-month follow-up, comparing the intervention (REACH) with usual care. REACH was provided by trained professionals and included a patient-centered, interdisciplinary approach starting directly after hospital discharge. Primary outcomes were patient safety, satisfaction, adherence, referral need and health care usage. Secondary outcomes, measured at 3 timepoints, were functional exercise capacity, self-perceived health status, health-related quality of life (HRQoL), return to work and psychotrauma. Risk of undernutrition was assessed at baseline.

RESULTS

43 patients with a median mechanical ventilation duration of 8 (IQR:10) days, were included in the study and 79.1% completed 6-month follow-up. 19 patients received the intervention, 23 received usual care. Groups were similar for gender distribution and ICU length of stay. No adverse events occurred. REACH participants showed higher satisfaction with treatment and reported more allied health professional visits, while the usual care group reported more visits to medical specialists. Qualitative analysis identified positive experiences among REACH-professionals related to providing state-of-the-art interventions and sharing knowledge and expertise within an interprofessional network. Similar recovery was seen between groups on all secondary outcomes, but neither group reached reference values for HRQoL at 6 months. Larger return to work rates were seen in the REACH group. Prevalence of undernutrition at hospital discharge was high in both groups (> 80%), warranting the need for careful tuning of physical therapy and nutritional interventions.

CONCLUSIONS

This study shows that providing early, home-based rehabilitation interventions for patients with PICS-related symptoms is feasible and perceived positively by patients and professionals. When provided in an interdisciplinary collaborative network state of the art, person-centered interventions can be tailored to individual needs potentially increasing patient satisfaction, adherence, and efficacy. Registered in the Dutch Trial register: NL7792: https://www.trialregister.nl/trial/7792 , registered 7-06-2019.

CE: Monitoring Adult Patients for Intolerance to Gastric Tube Feedings

ABSTRACT

Gastric tube feeding is a common and valuable intervention for patients in a variety of care settings. While tube feeding can save the lives of patients for whom oral feeding isn't possible, intolerance to tube feeding is a potential complication. This article discusses risk factors for feeding intolerance; the assessment of signs and symptoms of feeding intolerance; the various means of assessing gastric emptying, including the practice of monitoring gastric residual volume (GRV); the controversy surrounding GRV monitoring in assessing feeding tolerance; and the special considerations for monitoring feeding tolerance in acutely and critically ill adults with coronavirus disease 2019. The author, a nurse researcher with extensive experience in the area of enteral feeding, briefly summarizes recommendations and guidelines for enteral feeding published by national and international health care organizations between 2015 and 2020, and offers her perspective on best nursing practices for monitoring food tolerance in adults.

Functional electrical stimulation-assisted cycle ergometry-based progressive mobility programme for mechanically ventilated patients: randomised controlled trial with 6 months follow-up

PURPOSE

Functional electrical stimulation-assisted cycle ergometry (FESCE) enables in-bed leg exercise independently of patients' volition. We hypothesised that early use of FESCE-based progressive mobility programme improves physical function in survivors of critical care after 6 months.

METHODS

We enrolled mechanically ventilated adults estimated to need >7 days of intensive care unit (ICU) stay into an assessor-blinded single centre randomised controlled trial to receive either FESCE-based protocolised or standard rehabilitation that continued up to day 28 or ICU discharge.

RESULTS

We randomised in 1:1 ratio 150 patients (age 61±15 years, Acute Physiology and Chronic Health Evaluation II 21±7) at a median of 21 (IQR 19-43) hours after admission to ICU. Mean rehabilitation duration of rehabilitation delivered to intervention versus control group was 82 (IQR 66-97) versus 53 (IQR 50-57) min per treatment day, p<0.001. At 6 months 42 (56%) and 46 (61%) patients in interventional and control groups, respectively, were alive and available to follow-up (81.5% of prespecified sample size). Their Physical Component Summary of SF-36 (primary outcome) was not different at 6 months (50 (IQR 21-69) vs 49 (IQR 26-77); p=0.26). At ICU discharge, there were no differences in the ICU length of stay, functional performance, rectus femoris cross-sectional diameter or muscle power despite the daily nitrogen balance was being 0.6 (95% CI 0.2 to 1.0; p=0.004) gN/m2 less negative in the intervention group.

CONCLUSION

Early delivery of FESCE-based protocolised rehabilitation to ICU patients does not improve physical functioning at 6 months in survivors.

TRIAL REGISTRATION NUMBER

NCT02864745.

Effects of the Level and Duration of Mobilization Therapy in the Surgical ICU on the Loss of the Ability to Live Independently: An International Prospective Cohort Study

OBJECTIVES

It is unclear whether early mobilization in the surgical ICU helps improve patients' functional recovery to a level that enables independent living. We assessed dose of mobilization (level + duration). We tested the research hypotheses that dose of mobilization predicts adverse discharge and that both duration of mobilization and maximum mobilization level predict adverse discharge.

DESIGN

International, prospective cohort study.

SETTING

Study conducted in five surgical ICUs at four different institutions.

PATIENTS

One hundred fifty patients who were functionally independent before admission (Barthel Index ≥ 70) and who were expected to stay in the ICU for greater than or equal to 72 hours.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Mobilization was quantified daily, and treatments from all healthcare providers were included. We developed and used the Mobilization Quantification Score that quantifies both level and duration of mobilization. We assessed the association between the dose of mobilization (level + duration; exposure) and adverse discharge disposition (loss of the ability to live independently; primary outcome). There was wide variability in the dose of mobilization across centers and patients, which could not be explained by patients' comorbidity or disease severity. Dose of mobilization was associated with reduced risk of adverse discharge (adjusted odds ratio, 0.21; 95%CI, 0.09-0.50; p < 0.001). Both level and duration explained variance of adverse discharge (adjusted odds ratio, 0.28; 95% CI, 0.12-0.65; p = 0.003; adjusted odds ratio, 0.14; 95% CI, 0.06-0.36; p < 0.001, respectively). Duration compared with the level of mobilization tended to explain more variance in adverse discharge (area under the curve duration 0.73; 95% CI, 0.64-0.82; area under the curve mobilization level 0.68; 95% CI, 0.58-0.77; p = 0.10).

CONCLUSIONS

We observed wide variability in dose of mobilization treatment applied, which could not be explained by patients' comorbidity or disease severity. High dose of mobilization is an independent predictor of patients' ability to live independently after discharge. Duration of mobilization sessions should be taken into account in future quality improvement and research projects.

Could Physical Therapy Interventions Be Adopted in the Management of Critically Ill Patients with COVID-19? A Scoping Review

As part of COVID-19 consequences, it has been estimated that 5% of patients affected by this disease will require admission to the intensive care unit (ICU), and physical therapy techniques have been implemented in patients with other conditions admitted to ICU. The aim of the present study is to summarize all the available information about the implementation of physical therapy management in critically ill patients. From three clinical guidelines already published, we performed a search in PubMed, Scopus, ScienceDirect, and CINAHL, including systematic reviews, clinical guidelines, and randomized controlled trials, among others. Data extraction was performed independently by two reviewers. Quality assessment was developed through the AMSTAR-2 tool and PEDro Scale. A narrative synthesis was performed and 29 studies were included. The information extracted has been classified into four folders: ICU environment in COVID-19 (security aspects and management of the patient), respiratory physiotherapy (general indications and contraindications, spontaneously breathing and mechanically ventilated patient approaches), positional treatment, and exercise therapy (safety aspects and progression). The implementation of physiotherapy in patients affected with COVID-19 admitted to the ICU is a necessary strategy that prevents complications and contributes to the stabilization of patients in critical periods, facilitating their recovery.

Patient-reported physical functioning is limited in almost half of critical illness survivors 1-year after ICU-admission: A retrospective single-centre study

Post-intensive care unit (ICU) sequelae, including physical and mental health problems, are relatively unexplored. Characteristics commonly used to predict outcome lack prognostic value when it comes to long-term physical recovery. Therefore, the objective of this study was to assess the incidence of non-recovery in long-stay ICU-patients. In this single-centre study, retrospective data of adults with an ICU stay >48 hours who visited the specialized post-ICU clinic, and completed the Dutch RAND 36-item Short Form questionnaire at 3 and 12 months post-ICU, were retrieved from electronic patient records. In cases where physical functioning scores at 12 months were below reference values, patients were allocated to the physical non-recovery (NR) group. Significantly different baseline and (post-)ICU-characteristics were assessed for correlations with physical recovery at 12 months post-ICU. Of 250 patients, 110 (44%) fulfilled the criteria for the NR-group. Neither the severity of illness, type of admission, nor presence of sepsis did not differ between groups. However, NR-patients had a higher age, were more often female, and had a higher incidence of co-morbidities. Shorter LOS ICU, lower incidence of medical comorbidities, and better physical performance at 3 months were significantly correlated with 1-year physical recovery. Comorbidities and reduced physical functioning at 3 months were identified as independent risk-factors for long-term physical non-recovery. In conclusion, a substantial proportion of long-stay ICU-patients who visited the standard care post-ICU clinic did not fulfil the criteria for full physical recovery at 12 months post-ICU. Commonly used ICU-characteristics, such as severity of illness, do not have sufficient prognostic value when it comes to long-term recovery of health-related quality of life.

Guillain-Barré syndrome and COVID-19: association or coincidence

COVID-19 is a novel disease best known to cause a cough, fever and respiratory failure. Recently, it has been recognised that COVID-19 may present in multi-systemic ways which can cause diagnostic uncertainty or error.We present a patient who attended hospital with features of Guillain-Barré syndrome (GBS) before developing clinical and radiological findings of COVID-19. While the authors recognise that neurological complications have been reported following COVID-19 infection, to their knowledge this report describes a unique presentation of GBS without preceding COVID-19 symptoms.Since these conditions may have considerable overlapping features including respiratory failure and (following prolonged critical care admission) profound weakness, it is possible that one diagnosis may be overlooked. Raising awareness of a possible association between these conditions is important so both are considered allowing appropriate investigations to be arranged to optimise the chance of neurological recovery and survival, while also protecting staff from potentially unrecognised COVID-19.

Oral Nutrition during and after Critical Illness: SPICES for Quality of Care!

Malnutrition is associated to poor outcomes in critically ill patients. Oral nutrition is the route of feeding in less than half of the patients during the intensive care unit (ICU) stay and in the majority of ICU survivors. There are growing data indicating that insufficient and/or inadequate intakes in macronutrients and micronutrients are prevalent within these populations. The present narrative review focuses on barriers to food intakes and considers the different points that should be addressed in order to optimize oral intakes, both during and after ICU stay. They are gathered in the SPICES concept, which should help ICU teams improve the quality of nutrition care following 5 themes: swallowing disorders screening and management, patient global status overview, involvement of dieticians and nutritionists, clinical evaluation of nutritional intakes and outcomes, and finally, supplementation in macro-or micronutrients.

[Post-COVID-19 rehabilitation; a matter of customisation]

In the early phase of the COVID-19 pandemic, knowledge about the natural course of recovery of COVID-19 is limited. We therefore describe - based on generic knowledge of post IC syndrome (PICS) and (pulmonary) rehabilitation - the possibilities to organize personalized rehabilitation programs in several care settings. To illustrate variety in need for rehabilitation, we described three cases of critical COVID-19 disease survivors after treatment in the intensive care unit. Some patients require immediate rehabilitation following hospitalization, but rehabilitation may also be initiated in the home environment. For the latter population monitoring of progress and recovery should be organized to assess whether a more intensified multidisciplinary rehabilitation program is needed. This may be initiated in one of the medical rehabilitation centers or in pulmonary rehabilitation centers. Post-COVID-19 rehabilitation, regardless of the specific form, should be patient-centered and multidisciplinary organized.

Lung ultrasound as a tool to guide respiratory physiotherapy

Lung ultrasound (LUS) is becoming an invaluable tool in the management of critically ill patients. We report two cases showing the importance of LUS as a guide to optimize respiratory physiotherapy in the intensive care unit, allowing a successful lung donation process and to redirect the physiotherapist's approach. The use of LUS requires an adequate training but it is becoming an important tool in management algorithms for critically ill patients.

The 6 Ps of post-ICU recovery: application of a shared conceptual model

PURPOSE OF REVIEW

We aimed to explore, through a conceptual model, how we can maximize the post-ICU recovery of patients with ICU-acquired weakness (ICU-AW). The '6 Ps' were used to structure our research questions, what are the Predisposing (pre-ICU patient characteristics), Precipitating (ICU exposures) and Perpetuating (hinder recovery) risk factors for ICU-AW (Problem) and what Protective strategies and Proactive treatment can we adopt to improve muscle mass, strength and function of these patients?

RECENT FINDINGS

Examination of the relationship between pre-ICU patient characteristics with ICU-AW and post-ICU factors that prolong recovery are limited. Our understanding of the pathophysiology of the condition is improving, however, much of the biological mechanisms of ICU-AW and persistent weakness remain unknown. Investigation into the ICU-AW phenotype and prediction tools would be of great clinical utility. Further research on ICU-AW muscle biology and recovery may permit the application of precision and personalized medicine to therapeutic interventions.

SUMMARY

A structured approach to clinical practice and future research to better understand the mechanism (Problem), and identify Predisposing, Precipitating and Perpetuating risk factors will advance the field in better managing ICU-AW through implementation of Protective strategies and Proactive multimodal treatments.

Novel approaches to metabolic assessment and structured exercise to promote recovery in ICU survivors

PURPOSE OF REVIEW

Survivorship or addressing impaired quality of life (QoL) in ICU survivors has been named 'the defining challenge of critical care' for this century to address this challenge; in addition to optimal nutrition, we must learn to employ targeted metabolic/muscle assessment techniques and utilize structured, progressive ICU rehabilitative strategies.

RECENT FINDINGS

Objective measurement tools such as ccardiopulmonary exercise testing (CPET) and muscle-specific ultrasound show great promise to assess/treat post-ICU physical dysfunction. CPET is showing that systemic mitochondrial dysfunction may underlie development and persistence of poor post-ICU functional recovery. Finally, recent data indicate that we are poor at delivering effective, early ICU rehabilitation and that there is limited benefit of currently employed later ICU rehabilitation on ICU-acquired weakness and QoL outcomes.

SUMMARY

The combination of nutrition with effective, early rehabilitation is highly likely to be essential to optimize muscle mass/strength and physical function in ICU survivors. Currently, technologies such as muscle-specific ultrasound and CPET testing show great promise to guide ICU muscle/functional recovery. Further, we must evolve improved ICU-rehabilitation strategies, as current methods are not consistently improving outcomes. In conclusion, we must continue to look to other areas of medicine and to athletes if we hope to ultimately improve 'ICU Survivorship'.

Clinician perception of long-term survival at the point of critical care discharge: a prospective cohort study

Critical care survivors suffer persistent morbidity and increased risk of mortality as compared with the general population. Nevertheless, there are no standardised tools to identify at-risk patients. Our aim was to establish whether the Sabadell score, a simple tool applied by the treating clinician upon critical care discharge, was independently associated with 5-year mortality through a prospective observational cohort study of adults admitted to a general critical care unit. The Sabadell score, which is a measure of clinician-assigned survival perception, was applied to all patients from September 2011 to December 2017. The primary outcome was 5-year mortality, assessed using a multivariable flexible parametric survival analysis adjusted for baseline characteristics and clinically relevant covariates. We studied 5954 patients with a minimum of 18 months follow-up. Mean (SD) age was 59.5 (17.0) years and 3397 (57.1%) patients were men. We categorised 2287 (38.4%) patients as Sadabell 0; 2854 (47.9%) as Sadabell 1; 629 (10.5%) as Sadabell 2; and 183 (3.1%) as Sadabell 3. Adjusted hazard ratios for mortality were 2.1 (95%CI 1.9-2.4); 4.0 (95%CI 3.4-4.6); and 21.0 (95%CI 17.2-25.7), respectively. Sabadell 3 patients had 99.9%, 99.5%, 98.5% and 87.4% mortality at 5 years for patients in the age brackets ≥ 80, 60-79, 40-59 and 16-39 years, respectively. Sabadell 2 patients had 71.0%, 52.7%, 44.8% and 23.7% 5-year mortality for these same age categories. The Sabadell score was independently associated with 5-year survival after critical care discharge. These findings can be used to guide provision of increased support for patients after critical care discharge and/or informed discussions with patients and relatives about dying to ascertain their future wishes.

Rehabilitation After Critical Illness in People With COVID-19 Infection

The current COVID-19 pandemic will place enormous pressure on healthcare systems around the world. Large numbers of people are predicted to become critically ill with acute respiratory distress syndrome and will require management in intensive care units. High levels of physical, cognitive, and psychosocial impairments can be anticipated. Rehabilitation providers will serve as an important link in the continuum of care, helping move patients on from acute sites to eventual discharge to the community. Likely impairment patterns, considerations for healthcare practitioner resilience, and organization of services to meet demand are discussed. Innovative approaches to care, such as virtual rehabilitation, are likely to become common in this environment.

Response to physical rehabilitation and recovery trajectories following critical illness: individual participant data meta-analysis protocol

INTRODUCTION

The number of inconclusive physical rehabilitation randomised controlled trials for patients with critical illness is increasing. Evidence suggests critical illness patient subgroups may exist that benefit from targeted physical rehabilitation interventions that could improve their recovery trajectory. We aim to identify critical illness patient subgroups that respond to physical rehabilitation and map recovery trajectories according to physical function and quality of life outcomes. Additionally, the utilisation of healthcare resources will be examined for subgroups identified.

METHODS AND ANALYSIS

This is an individual participant data meta-analysis protocol. A systematic literature review was conducted for randomised controlled trials that delivered additional physical rehabilitation for patients with critical illness during their acute hospital stay, assessed chronic disease burden, with a minimum follow-up period of 3 months measuring performance-based physical function and health-related quality of life outcomes. From 2178 records retrieved in the systematic literature review, four eligible trials were identified by two independent reviewers. Principal investigators of eligible trials were invited to contribute their data to this individual participant data meta-analysis. Risk of bias will be assessed (Cochrane risk of bias tool for randomised trials). Participant and trial characteristics, interventions and outcomes data of included studies will be summarised. Meta-analyses will entail a one-stage model, which will account for the heterogeneity across and the clustering between studies. Multiple imputation using chained equations will be used to account for the missing data.

ETHICS AND DISSEMINATION

This individual participant data meta-analysis does not require ethical review as anonymised participant data will be used and no new data collected. Additionally, eligible trials were granted approval by institutional review boards or research ethics committees and informed consent was provided for participants. Data sharing agreements are in place permitting contribution of data. The study findings will be disseminated at conferences and through peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42019152526.

Dynamic Pituitary-Adrenal Interactions in the Critically Ill after Cardiac Surgery

CONTEXT

Patients with critical illness are thought to be at risk of adrenal insufficiency. There are no models of dynamic hypothalamic-pituitary-adrenal (HPA) axis function in this group of patients and thus current methods of diagnosis are based on aggregated, static models.

OBJECTIVE

To characterize the secretory dynamics of the HPA axis in the critically ill (CI) after cardiac surgery.

DESIGN

Mathematical modeling of cohorts.

SETTING

Cardiac critical care unit.

PATIENTS

20 male patients CI at least 48 hours after cardiac surgery and 19 healthy (H) male volunteers.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Measures of hormone secretory dynamics were generated from serum adrenocorticotrophic hormone (ACTH) sampled every hour and total cortisol every 10 min for 24 h.

RESULTS

All CI patients had pulsatile ACTH and cortisol profiles. CI patients had similar ACTH secretion (1036.4 [737.6] pg/mL/24 h) compared to the H volunteers (1502.3 [1152.2] pg/mL/24 h; P = .20), but increased cortisol secretion (CI: 14 447.0 [5709.3] vs H: 5915.5 [1686.7)] nmol/L/24 h; P < .0001). This increase in cortisol was due to nonpulsatile (CI: 9253.4 [3348.8] vs H: 960 [589.0] nmol/L/24 h, P < .0001), rather than pulsatile cortisol secretion (CI: 5193.1 [3018.5] vs H: 4955.1 [1753.6] nmol/L/24 h; P = .43). Seven (35%) of the 20 CI patients had cortisol pulse nadirs below the current international guideline threshold for critical illness-related corticosteroid insufficiency, but an overall secretion that would not be considered deficient.

CONCLUSIONS

This study supports the premise that current tests of HPA axis function are unhelpful in the diagnosis of adrenal insufficiency in the CI. The reduced ACTH and increase in nonpulsatile cortisol secretion imply that the secretion of cortisol is driven by factors outside the HPA axis in critical illness.

Impact of a Progressive Mobility Program on the Functional Status, Respiratory, and Muscular Systems of ICU Patients: A Randomized and Controlled Trial

OBJECTIVES

The aim was to investigate whether patients who participated in a mobility program in the ICU performed better on functional status, muscle, mobility, and respiratory assessments upon discharge than patients who received conventional physiotherapy.

DESIGN

Randomized controlled trial.

SETTING

Blind evaluation.

PATIENTS

Adults with previous functional independence and without contraindications for mobilization were eligible.

INTERVENTIONS

The intervention group participated in an early and progressive mobility program with five levels of activity. The control group underwent the conventional treatment without a preestablished routine. We evaluated functional status, level of activity, respiratory status, muscle strength, and mobility at ICU discharge.

MEASUREMENTS AND MAIN RESULTS

We analyzed 49 patients in the control group and 50 patients in the intervention group. Our data showed patients with better functional status and more functionally independent patients in the intervention group compared with those in the control group (96% vs 44%; p < 0.001). The results of the sit-to-stand and 2-minute walk tests, as well as the results of the maximum voluntary ventilation tests, also varied between the groups. The intervention group had shorter ICU stays than the control group. Higher Barthel index scores were associated with the amount of activity and participation in the protocol. The benefits to functional status remained during follow-up.

CONCLUSIONS

Patients who participated in an ICU mobility program had better functional status at discharge from the ICU. The other benefits of the program included better performance in the mobility tests and improved maximum voluntary ventilation performance.

Nutrition intake in the post-ICU hospitalization period

PURPOSE OF REVIEW

The care of critically ill patients has evolved over recent years, resulting in significant reductions in mortality in developed countries; sometimes with prolonged issues with recovery. Nutrition research has focused on the early, acute period of critical illness, until more recently, where the post-ICU hospitalization period in critical care survivors has become a focus for nutrition rehabilitation. In this period, nutrition rehabilitation may be a vital component of recovery.

RECENT FINDINGS

Overall, oral nutrition is the most common mode of nutrition provision in the post-ICU period. Compared with oral intake alone, calorie and protein requirements can be better met with the addition of oral supplements and/or enteral nutrition to oral intake. However, calorie and protein intake remains below predicted targets in the post-ICU hospitalization period. Achieving nutrition targets are complex and multifactorial, but can primarily be grouped into three main areas: patient factors; clinician factors; and system factors.

SUMMARY

A nutrition intervention in the post-ICU hospitalization period may provide an opportunity to improve survival and functional recovery. However, there are multiple barriers to the delivery of calculated nutrition requirements in this period, a limited understanding of how this can be improved and how this translates into clinical benefit.

Life After the Storm: Surviving COVID-19

This article highlights the outcomes of COVID-19, from the perspective of surviving patients, health-care systems, and societies. It draws on first-person experience of what it is to go through and survive acute respiratory distress syndrome (ARDS) and multiple organ failure. It summarizes the research on the short- and long-term outcomes for critically ill patients. The physical, cognitive, and emotional sequalae are staggering. Health-care professionals and systems will have to step up to meet the challenge of caring for large numbers of COVID-19 patients after discharge. And societies will have to step up to the ethical questions that the pandemic has made so stark. What kind of societies do we want to be, in terms of guarding the welfare of our most vulnerable citizens?

General Adaptation in Critical Illness: Glucocorticoid Receptor-alpha Master Regulator of Homeostatic Corrections

In critical illness, homeostatic corrections representing the culmination of hundreds of millions of years of evolution, are modulated by the activated glucocorticoid receptor alpha (GRα) and are associated with an enormous bioenergetic and metabolic cost. Appreciation of how homeostatic corrections work and how they evolved provides a conceptual framework to understand the complex pathobiology of critical illness. Emerging literature place the activated GRα at the center of all phases of disease development and resolution, including activation and re-enforcement of innate immunity, downregulation of pro-inflammatory transcription factors, and restoration of anatomy and function. By the time critically ill patients necessitate vital organ support for survival, they have reached near exhaustion or exhaustion of neuroendocrine homeostatic compensation, cell bio-energetic and adaptation functions, and reserves of vital micronutrients. We review how critical illness-related corticosteroid insufficiency, mitochondrial dysfunction/damage, and hypovitaminosis collectively interact to accelerate an anti-homeostatic active process of natural selection. Importantly, the allostatic overload imposed by these homeostatic corrections impacts negatively on both acute and long-term morbidity and mortality. Since the bioenergetic and metabolic reserves to support homeostatic corrections are time-limited, early interventions should be directed at increasing GRα and mitochondria number and function. Present understanding of the activated GC-GRα's role in immunomodulation and disease resolution should be taken into account when re-evaluating how to administer glucocorticoid treatment and co-interventions to improve cellular responsiveness. The activated GRα interdependence with functional mitochondria and three vitamin reserves (B1, C, and D) provides a rationale for co-interventions that include prolonged glucocorticoid treatment in association with rapid correction of hypovitaminosis.

Healing Status of Pressure Injuries Among Critically Ill Patients in a Turkish Hospital: A Descriptive, Retrospective Study

Evaluating the healing status of pressure injuries is important to planning medical and nursing care.

PURPOSE

A descriptive, retrospective study was conducted to determine the healing status of pressure injuries among critically ill immobile patients.

METHODS

Data were obtained via medical record review of all patients admitted to a Turkish university hospital's anesthesiology intensive care unit (ICU) between January 2008 and December 2015. Demographic (age, gender), medical (comorbidities, diagnosis, length of ICU stay), and pressure injury characteristics (number, location, stage, healing status, length, width, exudate amount, tissue type) were evaluated along with Pressure Ulcer Scale for Healing (PUSH) Tool scores. Data from all patients >18 years of age with an ICU stay >24 hours who had a pressure injury and whose records were complete were included in the study. Data were expressed as number, percentage, and mean and median values. Wilcoxon test, Spearman's correlation analysis, and chi-square test were performed as appropriate. Pressure injuries were considered healed when the PUSH score equaled zero.

RESULTS

The study sample comprised 359 patients (60.97 ± 19.31 [range 19-95] years, 217 men, median length of stay 25 [range 1-363] days) with 672 pressure injuries. Most pressure injuries were located on the coccyx (278 [41.4%]), and 153 (22.8%) healed during ICU stay. Older age (r = 0.167; P = .002) and length of ICU stay (r = 0.238; P = .0001) were significantly correlated with having multiple pressure injuries. There was a statistically significant relationship between pressure injury location and stage and healing status (χ2 = 28.993, P = .0001; and χ2 = 60.200, P = .001, respectively). The lowest percentage of injuries healed were on the coccyx and were stage 4 and unstageable. Overall, the mean first PUSH score was significantly higher than the last assessment score (8.99 ± 3.82 to 7.28 ± 5.22, respectively; z = -10.807; P = .0001).

CONCLUSION

Many immobile ICU patients had multiple pressure injuries, especially patients who were older and who had a longer length of stay. Healing scores for pressure injuries were better at discharge or transfer and 22% of injuries were healed. Prospective studies comparing all factors that may contribute to pressure injury healing are warranted. .

Feasibility, safety, and functional recovery after active rehabilitation in critically ill surgical patients

BACKGROUND

The characteristics of critically ill surgical patients differ from those of medical patients. Few studies have evaluated rehabilitation in surgical intensive care units (SICUs), particularly in non-Western countries and in elderly patients.

OBJECTIVE

The objective of this study was to investigate the rehabilitation characteristics, safety, and functional recovery in non-Western SICU patients.

METHODS

Data from patients who received active rehabilitation in 2016 were retrospectively reviewed. Clinical characteristics, functional recovery, and safety were investigated and compared in patients aged <65 or ≥65 years. Potential safety events were also compared between the two age groups and according to the reason for SICU admission.

RESULTS

Data from 157 patients were included in the analysis. The number of patients who were able to stand or walk increased from the beginning of rehabilitation to the time of ICU discharge (from 52 to 102 patients, P < 0.01). The Activity Measure for Post-Acute Care (AM-PAC) score also increased during rehabilitation (from 11.6 to 13.9, P < 0.01). Functional recovery did not differ between the two age groups. During 780 rehabilitation sessions, 23 potential safety events (3.0%) were noted; no significant differences were seen between the two age groups. A significant difference was noted when patients were grouped according to the reason for SICU admission (1.7% in postoperative care patients vs 4.5% in patients admitted for other reasons, P = 0.02).

CONCLUSIONS

Active rehabilitation in critically ill surgical patients is feasible and safe and resulted in improved mobility, regardless of age. However, the reason for SICU admission should be considered.

Exploring Patients' Goals Within the Intensive Care Unit Rehabilitation Setting

BACKGROUND

The number of patients surviving critical care is increasing. Quality of life after critical care is known to be poor for some patients. The evidence base for effective rehabilitation interventions in the period following a stay in an intensive care unit is limited.

OBJECTIVES

To understand what rehabilitation goals are important to patients after critical care discharge.

METHODS

This prospective study, which was undertaken during an intensive care unit recovery program, explored the recovery goals of 43 patients. Framework analysis was used to extract prevalent themes and identify the important components of recovery from the patients' perspective.

RESULTS

Participants described diverse goals for their post-intensive care unit recovery. Most goals were about health-related quality of life, including physical goals and rehabilitation. Although health was central to many of the participants' individual recovery aims, themes of family and social engagement and adopting appropriate goal trajectories also emerged within patient goals. Individual strategies for reaching these goals varied, and patients had different aspirations about what they could achieve.

CONCLUSIONS

Patients' aspirations for their intensive care unit recovery are diverse. Design of postdischarge care can be informed by this greater understanding of the heterogeneous starting points and goal trajectories of survivors of critical illness.

Framing the future: Family preparedness for care transitions of critically ill children

INTRODUCTION

Improving family centered care in the PICU requires understanding the milestones that families need assistance preparing for as well as factors that facilitate or obstruct preparedness. We present a model of family preparedness for transitions in the PICU based on semistructured interviews with clinicians and families that is designed to improve family centered care through the reduction of failed or traumatic transitions.

METHOD

We conducted semistructured interviews with 20 clinicians and 25 families in an academic PICU. Transcript analysis focused on identifying factors facilitating or obstructing family preparedness for care transitions. We analyzed interview transcripts for emergent themes and metathemes using grounded theory methodology.

RESULTS

Family preparedness for care transitions is dependent upon both cognitive and emotional preparedness. Six metathemes form a novel model for understanding the factors influencing both components of preparedness and their interrelationship. Specifically, family preparedness is influenced by (a) individualized backgrounds, coping skills, and support systems as well as the (b) emotional context, (c) care environment, (d) course of care, (e) content of preparatory information, and (f) manner in which care is coordinated to effectively deliver information. We also describe 10 transitional categories that provide context for application of the model.

DISCUSSION

Cognitive and emotional preparedness for care transitions in the PICU develops through attentiveness to six features. The conceptual model presented here will allow clinicians to support family centered care through interventions to facilitate a shared development of expectations for the future and reduce the risk of failed or traumatic transitions. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Nutrition and Exercise in Critical Illness Trial (NEXIS Trial): a protocol of a multicentred, randomised controlled trial of combined cycle ergometry and amino acid supplementation commenced early during critical illness

INTRODUCTION

Survivors of critical illness often experience significant morbidities, including muscle weakness and impairments in physical functioning. This muscle weakness is associated with longer duration mechanical ventilation, greater hospital costs and increased postdischarge impairments in physical function, quality of life and survival. Compared with standard of care, the benefits of greater protein intake combined with structured exercise started early after the onset of critical illness remain uncertain. However, the combination of protein supplementation and exercise in other populations has demonstrated positive effects on strength and function. In the present study, we will evaluate the effects of a combination of early implementation of intravenous amino acid supplementation and in-bed cycle ergometry exercise versus a 'usual care' control group in patients with acute respiratory failure requiring mechanical ventilation in an intensive care unit (ICU).

METHODS AND ANALYSIS

In this multicentre, assessor-blinded, randomised controlled trial, we will randomise 142 patients in a 1:1 ratio to usual care (which commonly consists of minimal exercise and under-achievement of guideline-recommended caloric and protein intake goals) versus a combined intravenous amino acid supplementation and in-bed cycle ergometery exercise intervention. We hypothesise that this novel combined intervention will (1) improve physical functioning at hospital discharge; (2) reduce muscle wasting with improved amino acid metabolism and protein synthesis in-hospital and (3) improve patient-reported outcomes and healthcare resource utilisation at 6 months after enrolment. Key cointerventions will be standardised. In-hospital outcome assessments will be conducted at baseline, ICU discharge and hospital discharge. An intent-to-treat analysis will be used to analyse all data with additional per-protocol analyses.

ETHICS AND DISSEMINATION

The trial received ethics approval at each institution and enrolment has begun. These results will inform both clinical practice and future research in the area. We plan to disseminate trial results in peer-reviewed journals, at national and international conferences, and via nutritional and rehabilitation-focused electronic education and knowledge translation platforms.

TRIAL REGISTRATION NUMBER

NCT03021902; Pre-results.

Risk factors for ventilator-associated events: A prospective cohort study

BACKGROUND

In January 2013, the Centers for Disease Control and Prevention released new surveillance definitions for ventilator-associated event (VAE) to replace ventilator-associated pneumonia (VAP) in adult patients. VAEs are associated with prolonged mechanical ventilation and hospital death, but little is known about their risk factors and how best to prevent them.

METHODS

We compared VAE cases with non-VAE cases with regard to demographics, comorbidities, sedative exposures, opioids exposures, paralytic exposures, routes of nutrition, blood products, gastric retention, and fluid balance. Patients mechanically ventilated for ≥4 days between January 1, 2017, and December 31, 2017, in 2 adult intensive care units of a tertiary care teaching hospital in China were included.

RESULTS

On multivariable logistic regression, significant risk factors for VAEs were positive daily fluid balances of ≥ 50 mL between day of intubation and the fourth day of mechanical ventilation (relative risk [RR], 8.39; 95% confidence interval [CI], 2.99-23.50), sedative administered between the first day and the fourth day of invasive mechanical ventilation (RR, 15.69; 95% CI, 1.62-152.06), and daily gastric retention of ≥200 mL between day of intubation and the fourth day of mechanical ventilation (RR, 9.27; 95% CI, 1.89-45.47).

CONCLUSIONS

Positive daily fluid balances of ≥50 mL, sedatives administered, and gastric retention of ≥200 mL are risk factors for VAEs. Intervention studies are needed to determine if targeting these risk factors can lower VAE rates.

Does enhanced physical rehabilitation following intensive care unit discharge improve outcomes in patients who received mechanical ventilation? A systematic review and meta-analysis

OBJECTIVE

We aimed to determine whether enhanced physical rehabilitation following intensive care unit (ICU) discharge improves activities-of-daily-living function, quality of life (QOL) and mortality among patients who received mechanical ventilation in the ICU.

DESIGN

Systematic review and meta-analysis using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

DATA SOURCES

MEDLINE, Embase, CENTRAL, PEDro and WHO International Clinical Trials Registry Platform searched through January 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included randomised controlled trials assessing the effect of post-ICU rehabilitation designed to either commence earlier and/or be more intensive than the protocol employed in the control group. Only adults who received mechanical ventilation for >24 hours were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed risk of bias. Standard mean differences (SMDs) with 95% CIs were calculated for QOL, and pooled risk ratios (RRs) with 95% CIs are provided for mortality. We assessed heterogeneity based on I² and the certainty of evidence based on the GRADE approach.

RESULTS

Ten trials (enrolling 1110 patients) compared physical rehabilitation with usual care or no intervention after ICU discharge. Regarding QOL, the SMD (95% CI) between the intervention and control groups for the physical and mental component summary scores was 0.06 (-0.12 to 0.24) and -0.04 (-0.20 to 0.11), respectively. Rehabilitation did not significantly decrease long-term mortality (RR 1.05, 95% CI 0.66 to 1.66). The analysed trials did not report activities-of-daily-living data. The certainty of the evidence for QOL and mortality was moderate.

CONCLUSIONS

Enhanced physical rehabilitation following ICU discharge may make little or no difference to QOL or mortality among patients who received mechanical ventilation in the ICU. Given the wide CIs, further studies are needed to confirm the efficacy of intensive post-ICU rehabilitation in selected populations.

PROSPERO REGISTRATION NUMBER

CRD42017080532.

Correlates of Cognitive Load in Surrogate Decision Makers of the Critically III

Surrogate decision makers (SDMs) of the critically ill experience intense emotions and transient states of decision fatigue. These factors may increase the cognitive load experienced by electronic decision aids. This cross-sectional study explored the associations of emotion regulation (expressive suppression and cognitive reappraisal) and decision fatigue with cognitive load (intrinsic and extraneous) among a sample of 97 SDMs of the critically ill. After completing subjective measures of emotion regulation and decision fatigue, participants were exposed to an electronic decision aid and completed a subjective measurement of cognitive load. Multiple regression analyses indicated that decision fatigue predicted intrinsic cognitive load and expressive suppression predicted extraneous cognitive load. Emotion regulation and decision fatigue represent modifiable determinants of cognitive load among SDMs exposed to electronic decision aids.