Precipitants of post-traumatic stress disorder following intensive care: a hypothesis generating study of diversity in care

Objective This prospective observational study was designed to explore the relationships between post-traumatic stress disorder (PTSD), patients' memories of the intensive care unit (ICU) and sedation practices. Design Prospective multi-centre follow-up study out to 3 months after ICU discharge. Setting Two district general hospitals and three teaching hospitals across Europe. Patients and participants Two hundred and thirty-eight recovering, post-ventilated ICU patients. Interventions None. Measurements and results Assessment of patients' memories of ICU was undertaken at 1–2 weeks post ICU discharge. Patients' psychological recovery was assessed by examining the level of PTSD-related symptoms and rate of PTSD by 3 months post ICU. The rate of defined PTSD was 9.2%, ranging from 3.2% to 14.8% in the different study ICUs. Independent of case mix and illness severity, the factors found to be related to the development of PTSD were recall of delusional memories, prolonged sedation, and physical restraint with no sedation. Conclusion The development of PTSD following critical illness is associated with a number of different precipitating factors that are in part related to how patients are cared for within intensive care. This study raises the hypothesis that the impact of care within the ICU has an impact on subsequent psychological morbidity and therefore must be assessed in future studies looking at the way patients are sedated in the ICU and how physical restraint is used.     

Post-ICU consequences of patient wakefulness and sedative exposure during mechanical ventilation

Objective To determine the relationship between measures of critical illness (sedative/analgesic administration, wakefulness and organ dysfunction), intensive care unit (ICU) recall and symptoms of posttraumatic stress disorder. Design Prospective, observational study with post-ICU follow-up. Setting Medical and surgical ICUs at a teaching hospital. Patients Two hundred seventy-seven subjects requiring > 36 h of mechanical ventilation were enrolled; 149 completed follow-up interviews 2 months later and 80 at 6 months. Interventions None. Results ICU recall was greater for events occurring at the end of critical illness; however, 18% of subjects had amnesia for the entire ICU course. Factual ICU recall was weakly associated with increased wakefulness during mechanical ventilation (r ² = 0.03–0.11, p< 0.05). Posttraumatic stress disorder prevalence was 17% at 2 months and 15% at 6 months. The avoidance-numbing cluster had the highest specificity (91%) for a formal diagnosis and the re-experiencing cluster had the lowest (69%). Recall of a delirious memory during critical illness was associated with more severe posttraumatic stress symptoms, but there was no association between posttraumatic stress symptoms and factual recall of ICU events. Neither ICU recall nor posttraumatic stress symptoms were associated with the intensity of sedative administration during mechanical ventilation. Posttraumatic stress symptoms were lowest in patients either the most awake during mechanical ventilation or the least awake. Conclusion Wakefulness during mechanical ventilation has a greater influence on post-ICU recall and posttraumatic stress symptoms than sedative drug exposure or severity of illness. It is difficult to predict the future psychological consequences of an individual patient's critical illness. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users. Work supported by a grant from the National Institutes of Health to C. R. W.     

Significant cognitive dysfunction in non-delirious patients identified during and persisting following critical illness

Objective Recent studies have shown significant cognitive problems some months after critical illness. However there has been no research examining cognitive function within the intensive care unit (ICU) in non-delirious patients.Design and setting A prospective study in an ICU.Patients and participants Using the Cambridge Neuropsychological Test Automated Battery (CANTAB), 30 long-stay, tracheal-intubated ICU patients were tested. Prior to testing on ICU the Confusion Assessment Measure (CAM-ICU) was administered and only those patients clearly not delirious and off sedation for several days were tested. The CANTAB tests were repeated a week after ICU discharge on the general ward and then again at 2 months. Sixteen patients completed the follow-up.Results While on ICU all 30 patients showed significant problems with strategic thinking and problem solving; 20 patients had some problems with memory. The degree of difficulty with problem solving on ICU was correlated with length of ICU stay (p = 0.011), age (p = 0.036) and length of hospital stay post ICU (p = 0.044). Problems with memory in ICU and on the general ward were correlated with admission APACHE II score (p = 0.004 and p = 0.005 respectively). At the 2-month follow-up 5 of 16 patients (31%) scored below the 25 percentile for memory and 8 of 16 (50%) below the 25 percentile for problem solving (Slater TA, Jones C, Griffiths RD, Wilson S, Benjamin K (2004) Cognitive impairment during and after intensive care: a pilot study. Intensive Care Med 30 [Suppl 1]:S199).Conclusions Difficulties with problem solving and poor memory remained a significant issue for 2 months after ICU discharge.     

Atrial fibrillation in trauma patients requiring intensive care

Objectives To evaluate the incidence and risk factors of atrial fibrillation (AF) in trauma patients. Design and setting Prospective observational study in a surgical intensive care unit (ICU). Patients All trauma patients admitted in the surgical ICU except those who had AF at admission. Measurements and results AF occurred in 16/293 patients (5.5%). AF patients were older, had a higher number of regions traumatized, and received more fluid therapy, transfusion products, and catecholamines. They more frequently experienced systemic inflammatory response syndrome, sepsis, shock, and acute renal failure and had higher scores of severity (Simplified Acute Physiology Score, SAPS II; Injury Severity Score). ICU length of stay and resources use were also increased. ICU and hospital mortality rates were twice higher in AF patients whereas standardized mortality ratio (observed/expected mortality by SAPS II) was similar in the two groups. We found five independent risk factors of developing AF: catecholamine use (OR = 5.7, 95% CI 1.7–19.1), SAPS II of 30 or higher (OR = 11.6, 95% CI 1.3–103.0), three or more regions traumatized (OR = 6.2, 95% CI 1.8–21.4), age 40 years or higher (OR = 6.3, CI 1.4–28.7), and systemic inflammatory response syndrome (OR = 4.4, 95% CI 1.2–16.1). Conclusions In addition to age and catecholamine use, inflammation and severity of injury may be involved in the development of AF in trauma patients. Our results suggest that AF could rather be a marker of a higher severity of illness without major effect on mortality. This article is discussed in the editorial available at: .     

Incidence,risk factors and consequences of ICU delirium

Objective Delirium in the critically ill is reported in 11–80% of patients. We estimated the incidence of delirium using a validated scale in a large cohort of ICU patients and determined the associated risk factors and outcomes. Design and setting Prospective study in a 16-bed medical-surgical intensive care unit (ICU). Patients 820 consecutive patients admitted to ICU for more than 24 h. Interventions Tools used were: the Intensive Care Delirium Screening Checklist for delirium, Richmond Agitation and Sedation Scale for sedation, and Numerical Rating Scale for pain. Risk factors were evaluated with univariate and multivariate analysis, and factors influencing mortality were determined using Cox regression. Results Delirium occurred in 31.8% of 764 patients. Risk of delirium was independently associated with a history of hypertension (OR 1.88, 95% CI 1.3–2.6), alcoholism (2.03, 1.2–3.2), and severity of illness (1.25, 1.03–1.07 per 5-point increment in APACHE II score) but not with age or corticosteroid use. Sedatives and analgesics increased the risk of delirium when used to induce coma (OR 3.2, 95% CI 1.5–6.8), and not otherwise. Delirium was linked to longer ICU stay (11.5 ± 11.5 vs. 4.4 ± 3.9 days), longer hospital stay (18.2 ± 15.7 vs. 13.2 ± 19.4 days), higher ICU mortality (19.7% vs. 10.3%), and higher hospital mortality (26.7% vs. 21.4%). Conclusion Delirium is associated with a history of hypertension and alcoholism, higher APACHE II score, and with clinical effects of sedative and analgesic drugs. This article is discussed in the editorial available at:     

Stressful experiences in relation to depth of sedation in mechanically ventilated patients

In mechanically ventilated patients, sedatives and analgesics are commonly used to ensure comfort, but there is no documented knowledge about the impact of depth of sedation on patients' perception of discomfort. The aim of this study was, therefore, to investigate the relationship between stressful experiences and intensive care sedation, including the depth of sedation. During 18 months, 313 intubated mechanically ventilated adults admitted to two general intensive care units (ICU) for more than 24 h were included. Patients (n = 250) were interviewed on the general ward 5 days after ICU discharge using the ICU Stressful Experiences Questionnaire. Patient data including sedation scores as measured by the Motor Activity Assessment Scale (MAAS) were collected from hospital records after the interview. Of the 206 patients with memories of the intensive care, 82% remembered at least one experience as quite a bit or extremely bothersome. Multivariate analyses showed that higher proportion of MAAS score 3 (indicating more periods of wakefulness), longer ICU stay and being admitted emergent were factors associated with remembering stressful experiences of the ICU as more bothersome. The findings indicate that the depth of sedation has an impact on patients' perception of stressful experiences and that light sedation compared with heavy seems to increase the risk of perceiving experiences in the ICU as more bothersome. In reducing discomfort, depth of sedation and patient comfort should be assessed regularly, non-pharmacological interventions taken into account and the use of sedatives and analgesics adapted to the individual requirements of the patient.     

After-hours admissions are not associated with increased risk-adjusted mortality in pediatric intensive care

Objective To examine the influence of time of admission on risk-adjusted mortality and length of stay for nonelective patients admitted to a pediatric intensive care unit (ICU) without 24-h per day in-house intensivist coverage. Design Data analyzed came from a comprehensive, prospectively collected ICU database. Setting A 12-bed pediatric ICU located in a university-affiliated tertiary referral children's hospital. Patients Subjects consisted of 4,456 consecutive nonelective patients admitted over a 10-year period (1997–2006). Interventions None. Measurements and results Patients were categorized according to time of admission to the ICU as either in-hours (0800–1800 Monday–Friday and 0800–1200 on weekends), when an intensivist is present in the ICU, or after-hours (all other times), when intensivists attend only on an as-needed basis. Multivariate logistic regression was used to assess the effect of time of admission on outcome after adjustment for severity of illness using the Paediatric Index of Mortality (PIM). Patients admitted after hours had a lower risk-adjusted mortality than those admitted during normal working hours, with an odds ratio for death of 0.712 (95% confidence interval 0.518–0.980, p = 0.037). Length of stay was also significantly shorter for patients admitted after hours (44.05 h vs. 50.0 h, p = 0.001). Conclusions A lack of in-house intensivist presence is not associated with any increase in mortality or length of stay for patients admitted to our pediatric ICU; on the contrary, after-hours admission in this cohort was associated with a decreased risk-adjusted mortality and a shorter length of stay.     

The effect of an algorithm-based sedation guideline on the duration of mechanical ventilation in an Australian intensive care unit

Objective To examine the effect of an algorithm-based sedation guideline developed in a North American intensive care unit (ICU) on the duration of mechanical ventilation of patients in an Australian ICU.Design and setting The intervention was tested in a pre-intervention, post-intervention comparative investigation in a 14-bed adult intensive care unit.Patients Adult mechanically ventilated patients were selected consecutively (n = 322). The pre-intervention and post-intervention groups were similar except for a higher number of patients with a neurological diagnosis in the pre-intervention group.Intervention An algorithm-based sedation guideline including a sedation scale was introduced using a multifaceted implementation strategy.Measurements and results The median duration of ventilation was 5.6 days in the post-intervention group, compared with 4.8 days for the pre-intervention group (P = 0.99). The length of stay was 8.2 days in the post-intervention group versus 7.1 days in the pre-intervention group (P = 0.04). There were no statistically significant differences for the other secondary outcomes, including the score on the Experience of Treatment in ICU 7 item questionnaire, number of tracheostomies and number of self-extubations. Records of compliance to recording the sedation score during both phases revealed that patients were slightly more deeply sedated when the guideline was used.Conclusions The use of the algorithm-based sedation guideline did not reduce duration of mechanical ventilation in the setting of this study.     

Memory, delusions, and the development of acute posttraumatic stress disorder-related symptoms after intensive care

OBJECTIVE: To examine prospectively the relationship between memories of intensive care (ICU) and levels of anxiety after ICU discharge, the stability of these memories with time, and their relationship to the development of acute posttraumatic stress disorder (PTSD)-related symptoms. DESIGN: Case series cohort assessed by interview at 2 and 8 wks after ICU discharge. SETTING: District general hospital (serving a population of 350,000) general intensive care unit. PATIENTS: Memories of ICU and anxiety levels were studied in 45 patients after ICU discharge. Thirty patients were examined again at 8 wks to assess memory stability and development of acute PTSD-related symptoms. MEASUREMENTS AND MAIN RESULTS: Standardized interviews and questionnaires were used to assess memory for ICU, anxiety, and depression 2 wks after ICU discharge. In addition, PTSD-related symptoms and panic were assessed 8 wks after ICU discharge. A total of 33 of 45 patients had delusional memories from ICU at 2 wks; nine of the patients with delusional memories had no factual memories, and these patients had higher anxiety levels 2 wks after ICU discharge (p < .0001). Thirty patients had paired assessments at 2 and 8 wks. Those patients who had no factual recall of ICU but had delusional memories at 2 wks scored highly for PTSD-related symptoms and panic attacks at 8 wks (p = .023 and .014, respectively). The only predictors of possible acute PTSD-related symptoms at the 8-wk assessment were trait anxiety (p = .006) and having delusional memories without recall of factual events in the ICU at 2 wks (p < .0001). Only delusional memories were retained over time, whereas the recall of factual events in the ICU declined. CONCLUSIONS: We propose that the development of acute PTSD-related symptoms may be related more to recall of delusions alone. This study suggests that even relatively unpleasant memories for real events during critical illness may give some protection from anxiety and the later development of PTSD-related symptoms when memories of delusions are prominent.     

Chest physiotherapy prolongs duration of ventilation in the critically ill ventilated for more than 48 hours

Objective This study aimed to determine the impact of providing chest physiotherapy after routine clinical assessment on the duration of mechanical ventilation, outcome and intensive care length of stay. Design and setting Single-centre, single-blind, prospective, randomised, controlled trial in a university hospital general intensive care unit. Patients and participants 180 patients requiring mechanical ventilation for more than 48 h. Interventions Patients randomly allocated, one group receiving physiotherapy as deemed appropriate by physiotherapists after routine daily assessments and another group acting as controls were limited to receiving decubitus care and tracheal suctioning. Measurements and results Primary endpoints were initial time to become ventilator-free, secondary endpoints included intensive care unit (ICU) and hospital mortality and ICU length of stay. Kaplan-Meier analysis censored for death revealed a significant prolongation of median time to become ventilator-free among patients receiving physiotherapy ( p = 0.047). The time taken for 50% of patients (median time) to become ventilator-free was 15 and 11 days, respectively, for physiotherapy and control groups. There were no differences between groups in ICU or hospital mortality rates, or length of ICU stay. The number of patients needing re-ventilation for respiratory reasons was similar in both groups.     

Intensive care unit acquired infection and organ failure

Objective To assess the temporal relationship between ICU-acquired infection (IAI) and the prevalence and severity of organ dysfunction or failure (OD/F). Design and setting Observational, single center study in a mixed intensive care unit of a university hospital. Patients We analyzed 1,191 patients hospitalized for more than 2 days during a 2-year observation period: 845 did not acquire IAI, 306 of whom had infection on admission (IOA); 346 did acquire IAI, 125 of whom had IOA. Measurements and results The SOFA score was calculated daily, both SOFAmax, the sum of the worst OD/F during the ICU stay, and SOFApreinf, the sum of the worst OD/F existing before the occurrence of the first IAI. The SAPS II and SOFA score of the first 24 h were significantly higher in patients with than in those without IAI. SOFApreinf of IAI patients was also higher than the SOFAmax of patients without IAI both in patients with (12.1 ± 4.6 vs. 8.9 ± 4.7) and those without IOA (9.2 ± 4.0 vs. 6.7 ± 3.5). SOFApreinf represented 85.7% of the value of SOFAmax in patients with IAI. SOFApreinf increased significantly with the occurrence of sepsis, severe sepsis, or septic shock during ICU stay. Severe sepsis and septic shock during ICU stay as well as SOFApreinf were part of the factors associated with hospital mortality. Conclusions IAI is significantly associated with hospital mortality; however, its contribution to OD/F is minor. Moreover, severity of IAI seems to be related to previous health status. This article is discussed in the editorial available at: .     

Informed consent for research in ICU obtained before ICU admission

Objective To analyze the procedure of the informed consent for ICU research obtained before ICU admission. Design Prospective, open, observational study. Setting 20-bed surgical ICU of a tertiary teaching university hospital and the ward before and after ICU. Patients Patients, scheduled for elective cardiac surgery, who accepted to participate in a coagulation study. Interventions Patients underwent the same informed consent procedure, including an oral presentation of the coagulation study and an informative leaflet the day before surgery on the ward. Measurements and results Between January and August 2001, we included 38 patients; 36 survived ICU. Ten to 12 days after surgery, 8/36 (22%) patients did not know they had participated in a study, and 9/36 (25%) could not recall the study purpose and the related risk. Patients with incomplete recall stayed longer in ICU [median (range): 4 (3–6) vs 3 (1–5) days; p = 0.004]. None of these patients (0/9 vs 10/27; p < 0.04) had read the informative leaflet AND asked at least one question during the informed consent procedure. Conclusions Even when the informed consent is obtained in the most optimal conditions for ICU research, its ethical value remains questionable. Indeed, a substantial number of patients were unaware of their study participation, or of the related purpose and risks. When the ICU stay is prolonged, we should at least repeatedly and actively (re)-inform patients about their study participation. Presented in part at the annual congress of the American Thoracic Society (ATS), May 2003, in Seattle, WA, USA     

Junctional ectopic tachycardia after surgery for congenital heart disease in children

Objective To determine incidence, predictors and outcome [intensive care unit (ICU) mortality and length of stay (LOS)] after postoperative junctional ectopic tachycardia (JET) in an unselected paediatric population. Design Patients with JET (n = 89) were compared with non-JET controls (n = 178) in a nested case–control study. Setting Tertiary ICU at Skejby Sygehus, Aarhus University Hospital, Denmark. Patients The patient records of all children (n = 874) who underwent corrective cardiac surgery on cardio-pulmonary bypass (CPB) between 1998 and 2005 were reviewed for postoperative JET. Methods and results The association between JET and its potential predictors was examined with multivariate conditional regression analyses. The overall incidence of JET was 10.2%. CPB duration > 90 min [adjusted odds ratio (OR) 2.6; 95% confidence interval (CI) 1.1–6.5], high inotropic requirements (adjusted OR 2.6; CI 1.2–5.9) and high postoperative levels of creatine kinase (CK)-MB (adjusted OR 3.1; CI 1.3–7.1) were associated with an increased risk of JET. ICU mortality was higher for patients with JET (13.5%; CI 7.2–22.4%) than for controls (1.7%; CI 0.3–4.8%), and LOS in ICU was 3 times higher in JET patients (median 2 vs. 7 days, p < 0.001). Conclusions JET occurred in approximately 10% of children following cardiac surgery and was associated with higher mortality and longer ICU stay. Risk factors included high inotropic requirements after surgery and extensive myocardial injury in terms of high CK-MB values and longer CPB duration.     

Insulin glargine supplementation during early management phase of diabetic ketoacidosis in children

Objective To study the effect of subcutaneous administration of insulin glargine on the rate of resolution of acidosis and intravenous insulin infusion requirement in children with moderate and severe diabetic ketoacidosis (DKA). Study design Retrospective cohort study. Setting Pediatric intensive care unit of a university-based children's hospital. Patients Children with moderate to severe DKA admitted between March 2001 and February 2003. Results The outcomes of children who received 0.3 units/kg of subcutaneous insulin glargine in the first 6 h of management in addition to the standard treatment (n = 12) were compared with those of children who received standard treatment alone (n = 59). Measured outcomes included dose of intravenous insulin required, duration of insulin infusion and acidosis correction time. The two groups were similar in demographics and severity of illness. The mean time for acidosis correction (venous pH ≥ 7.3) in the insulin glargine group was shorter than the standard therapy group (12.4 ± 2.9 h and 17.1 ± 6.2 h respectively, p < 0.001). The insulin infusion time was shorter in the insulin glargine group (14.8 ± 6.0 h vs 24.4 ± 9.0 h, p < 0.001). There was a trend towards shorter total hospital stay in the glargine group (3.2 ± 1.0 days vs 3.72 ± 1.06 days). Conclusions In our small series of children with moderate and severe DKA, supplementing with subcutaneous insulin glargine led to a faster resolution of acidosis without any adverse effects. This could potentially lead to a shorter need for insulin infusion and a shorter ICU length of stay.     

Incidence, risk factors, and outcome of aspiration pneumonitis in ICU overdose patients

Objective To assess the incidence and outcome of clinically significant aspiration pneumonitis in intensive care unit (ICU) overdose patients and to identify its predisposing factors.Design Retrospective cohort study.Setting Medical ICU of an academic tertiary care hospital.Patients A total of 273 consecutive overdose admissions.Measurements and results Clinically significant aspiration pneumonitis was defined as the occurrence of respiratory dysfunction in a patient with a localised infiltrate on chest X-ray within 72 h of admission. In our cohort we identified 47 patients (17%) with aspiration pneumonitis. Importantly, aspiration pneumonitis was associated with a higher incidence of cardiac arrest (6.4 vs 0.9%; p = 0.037) and an increased duration of both ICU stay and overall hospital stay [respectively: median 1 (interquartile range 1–3) vs 1 (1–2), p = 0.025; and median 2 (1–7) vs 1 (1–3), p < 0.001]. In multivariate logistic regression analysis, Glasgow Coma Scale (GCS) score [odds ratio (OR) for each point of GCS 0.8; 95% confidence interval (CI) 0.7–0.9; p = 0.001], ingestion of opiates (OR 4.5; 95% CI 1.7–11.6; p = 0.002), and white blood cell count (WBC) (OR for each increase in WBC of 10⁹/l 1.05; 95% CI 1.0–1.19; p = 0.049) were identified as independent risk factors.Conclusions Clinically relevant aspiration pneumonitis is a frequent complication in overdose patients admitted to the ICU. Moreover, aspiration pneumonitis is associated with a higher incidence of cardiac arrest and increased ICU and total in-hospital stay.     

Adult congenital heart disease: intensive care management and outcome prediction

Objective Improved patient survival and increasingly complex surgery have expanded the requirement for specialist care for patients with adult congenital heart disease (ACHD). Despite the recent publications of management guidelines for ACHD, data concerning optimal patterns of care in the peri-operative/critical care period of this challenging population are sparse. The aims of the current study were to therefore to determine the pattern of intensive care unit (ICU) management, resource utilisation and predictors of mortality in critically ill ACHD patients. Design, setting and patients Data were collected prospectively for patients with ACHD stratified for complexity of disease admitted to the ICU of a tertiary cardiothoracic centre (1997–2002). Multivariate analysis of pre-operative indices as predictors of mortality was performed. Of 342 ACHD admissions (total mortality 4.4%, simple 0%, moderate/complex 10.6%), the requirement for specialist investigations and interventions was high, reflected in ICU admission costs per patient (simple $5391 ± 130, moderate $13218 ± 261, complex $30074 ± 689). Standard severity of illness scoring systems did not accurately predict mortality; however, abnormal pre-operative thyroid function (p = 0.0048), creatinine (p = 0.0032) and bilirubin (p = 0.0021) were highly predictive of mortality. Conclusions Peri-operative mortality in patients with ACHD is low overall but varies with disease complexity. Such patients have a high requirement for specialist ICU investigation/intervention. Although standard severity of illness scoring is unhelpful, simple pre-operative parameters may predict peri-operative mortality. These findings reflect the requirement for specialist care, and have implications for planning service provision, training and operative consent in ACHD patients.     

Optimum sedation and analgesia in critical illness: we need to keep trying

Many studies have documented patients' distressing recollections of the intensive care unit (ICU). The study by van de Leur and colleagues, conducted in a group of surgical ICU patients with moderate severity of sickness, found that the frequency of such unpleasant memories was increased in those able to recall factual information about their stay in the ICU. The study did not include sedation scoring but it did use a simple tool to assess factual recall. This tool appeared reliable and could be easily applied in any ICU. Previous work strongly suggests that abolishing memory of ICU by using deep sedation would not be an appropriate response to these findings. Rather, we need to work on strategies that reduce distress by improving analgesia, reducing noxious stimuli (if possible) and, potentially, using pharmacology to produce a calm patient with minimal sedation. Achieving the latter is rarely possible today but it might become possible with future drug development.     

Intensive care outcome of adult patients operated on for congenital heart disease

Objective To describe the ICU outcome and the most frequent complications observed in adult patients operated on for a congenital heart disease. Design and setting Retrospective analysis of prospectively collected data and chart review in an adult cardiovascular ICU of a university hospital. Patients 156 patients older than 15 years with congenital heart disease undergoing cardiac surgery between June 2001 and June 2005. Results According to the initial cardiac malformation, patients were divided in four groups with different operative risk based on the Euroscore: those diagnosed bicuspid aortic valve (n = 73) had a score of 5, those with tetralogy of Fallot (n = 33) 5.5, those with simple cardiac defect (n = 26) 3, and those with complex malformations (n = 24) 6. Only two patients (one with tetralogy of Fallot and one with complex malformations) died during the hospitalization (1.2%). Conclusion Euroscore clearly overestimates the risk of surgery in this population of adults with congenital heart disease. Mortality and morbidity were low in those diagnosed bicuspid aortic valve, tetralogy of Fallot, or simple cardiac defect, justifying early surgery for incipient complications. Patients with complex congenital defect require prolonged ICU stay, sometimes with mechanical cardiac support, but their overall good outcome justifies these efforts.     

Factors related to memory absence and delusional memories in patients in intensive care units managed with light sedation

ObjectivesCurrently, light sedation is typically given to patients in intensive care units and studies have not extensively examined the factors related to absences or abnormalities of their memories. We, therefore, analysed the factors related to the absence/abnormalities of patients’ memories in intensive care units.Research MethodologyA secondary analysis of previously collected survey data examining patients’ experiences in an intensive care unit was undertaken (n = 405; women = 38%; median age = 70 years). To observe absent or distorted memories, patients were interviewed after leaving the intensive care unit. We analysed key factors through content analysis of the interviews and field notes.SettingThe intensive care unit of a university hospital. Main outcome measure: Patients’ absent or distorted memories after leaving the intensive care unit.ResultsHalf the patients reported an absence of memories. This was associated with old age and with longer duration of mechanical ventilation. Absent or fragmentary memories were not distressing. Fragmentary and fearful intensive care unit memories were associated with being older. Delusional memories, some of which reflected actual events, were present in 3% of patients.ConclusionAbsence of memories were not distressing, delusional memories occurred less and these memories could comprise of an event in ICU that is difficult for patients to understand.     

The prevalence and characteristics of anaemia at discharge home after intensive care

Objective To document the prevalence of anaemia among ICU survivors at the time of discharge home and to document red cell morphology among anaemic patients.Design and setting Observational cohort study in a single-centre teaching hospital.Patients and participants Three cohorts of ICU admissions over a 3-year period managed with restrictive ICU transfusion practice. The study group comprised the 283 patients who survived and were discharged directly home from our hospital.Measurements and results The median time from ICU discharge to hospital discharge was 13 days (IQR 6–22, range 1–119). Using the last recorded Hb concentration 77.4% (95% CI 72.2–82.1) of patients were anaemic, 32.5% (27.3–38.2) had Hb less than 100 g/l, and 11.3% (8.1–15.5) had Hb less than 90 g/l at hospital discharge. Patients who spent longer in intensive care and in hospital after ICU discharge were more likely to be discharged home anaemic. The strongest predictor of discharge home with Hb less than 100 g/l was Hb at the time of ICU discharge. Multivariate regression analysis showed patient age, gender, APACHE II score, and ICU length of stay not to be independent predictors after including the ICU discharge Hb. Among anaemic patients 82% had normochromic normocytic red cell indices, but 12% had red cell hypochromasia and/or microcytosis, which may indicate iron deficiency.Conclusions Anaemia is highly prevalent among survivors of critical illness and persists until hospital discharge. Most patients have red cell morphology similar to “anaemia of chronic disease”.Electronic supplementary material The electronic reference of this article is . The online full-text version of this article includes electronic supplementary material. This material is available to authorised users and can be accessed by means of the ESM button beneath the abstract or in the structured full-text article. To cite or link to this article you can use the above reference.