Sleep-related breathing disorders following discharge from intensive care

Objectives: To determine the incidence of sleep-related breathing disorders and nocturnal hypoxaemia in patients discharged from ICU following prolonged mechanical ventilation.¶Design: Prospective, consecutive patient observational study.¶Setting: The medical and surgical wards of a University Hospital.¶Patients and participants: Fifteen consecutive, adult patients discharged from the ICU who had received more than 48 h of mechanical ventilation were studied. Ten healthy volunteers acted as controls.¶Measurements and results: Overnight, multi-channel pneumographic studies were performed on all patients and controls. Chest and abdominal wall movement, air flow, oxygen saturation and snoring were continuously recorded. Data was analysed by both visual inspection of the traces and by computer-based algorithms. An apnoea/hypopnoea index was calculated for each patient and volunteer. Volunteers had an apnoea/hypopnoea index of less than 5 and had no episodes of nocturnal oxygen desaturation (SaO₂ < 90 %). Despite oxygen therapy 13/15 patients had episodes of desaturation and 9/15 spent more than 2 h with an SaO₂ < 90 %. Eleven patients had an abnormal apnoea/hypopnoea index (range 5–34 events/h). Four patients had predominantly obstructive events while 7 primarily had hypopnoeas.¶Conclusions: Significant overnight oxygen desaturation is common in patients discharged from ICU who have received prolonged mechanical ventilation. This group also has a significant incidence of sleep-related breathing disorders and this mechanism is likely to be important in the pathogenesis of the hypoxaemia.     

The effect of physiotherapy treatment on oxygen consumption and haemodynamics in patients who are critically ill

The purpose of this study was to determine metabolic and haemodynamic changes with and without physiotherapy treatment in haemodynamically stable, intubated and ventilated patients. This was a prospective, randomised cross-over study. Ten intubated, ventilated and haemodynamically stable patients underwent a 20 min physiotherapy treatment and a 20 min period of undisturbed side lying. Mean oxygen consumption (VO2mean) was measured on a minute-to-minute basis by indirect calorimetry. Mean arterial pressure (MAP) was recorded minutely from the indwelling arterial line and cardiac index (CI) was calculated from the indwelling pulmonary artery catheter. Time to recovery to within 5% of resting VO2 was also recorded. The results showed no significant increase in VO2mean with either positioning the patient in side lying or physiotherapy treatment (p = 0.17). Time to recovery to within 5% of baseline VO2 occurred within seven minutes for all patients and there was no significant difference between either physiotherapy treatment or positioning in side lying (p = 0.63). There were no significant differences in CI (p = 0.44) or MAP (p = 0.95) during physiotherapy treatment compared with undisturbed side lying. It is concluded that physiotherapy treatment does not significantly alter VO2mean or MAP and CI in stable intubated and ventilated patients.     

Sleep-related breathing disorders and rehabilitation outcome of stroke patients: a prospective study

OBJECTIVE: Sleep-related breathing disorder (SRBD) is more prevalent in stroke patients than in age- and sex-matched controls, but the relationship between SRBD, functional levels at admission, and subsequent recovery is unclear. We evaluated patients after a first stroke to determine the prevalence of SRBD and the influence of SRBD on the recovery of discharge functional status after a rehabilitation program. DESIGN: In a prospective study, 30 stroke patients were studied by continuous overnight pulse oximetry during sleep for the presence of desaturation events (fall of arterial saturation of > 4% from the baseline). The Respiratory Disturbance Index was defined as number of desaturations per hour of sleep. Functional assessment was done at admission using the FIM instrument. The patients were asked about total hours of sleep and the presence or absence of habitual snoring before and after the stroke. The outcome measure at discharge was the FIM score. RESULTS: On linear regression, after including the FIM score at admission, in the model, the Respiratory Disturbance Index score was negatively correlated with the FIM gain (coefficient, -0.635 +/- 0.27; P = 0.025), and together, the variables explained 20.9% of the total variance (adjusted r2). All patients with an admission FIM score of > or = 70 (only mild functional impairment) had a good outcome (FIM score of > 100 at discharge). However, only two of six of those with FIM scores of < 70 with SRBD (defined as a Respiratory Disturbance Index score of > 10) had significant improvement (> or = 30 points), whereas this occurred in seven of nine of those without SRBD (prevalence ratio, 0.43; 95% confidence interval, 0.13-1.40; P = 0.085) CONCLUSIONS: Even after adjusting for the admission functional status, the presence of hypoxic events during sleep predicts a poorer recovery, especially in stroke patients with poor function at admission.     

Systemic hemodynamic disorders in critically ill patients with intracranial hemorrhages

The paper analyzes systemic hemodynamic disorders in 45 victims of severe brain injury and patients with nontraumatic intracranial hemorrhages. The incidence of hypovolemia in patients with nontraumatic intracranial hemorrhages and victims of severe brain injury is 65.4% and 73.7%, respectively. Infusion therapy based on the estimation of routine hemodynamic parameters (blood pressure, heart rate, central venous pressure, daily fluid balance) could not prevent hypovolemia in the examinees and caused a high rate of sympathomimetic use in uncorrected volemic states.     

The role of transport intervals in outcomes for critically ill patients who are transferred to referral centers

Purpose

The aim of this study was to determine the association between transport intervals (including time from call to arrival of transport team at the sending hospital, time spent by the transport team in the sending hospital, and transport time between the sending and receiving hospital) and intensive care unit (ICU) and hospital length of stay and hospital mortality at the receiving hospital.

Materials and Methods

This was a retrospective, stratified cohort study involving all patients 15 years and older who were transferred from one hospital to another of equal or larger size in British Columbia, Canada, and who spent at least 1 day in an ICU or coronary care unit (CCU) at the receiving hospital during 1999 (n = 1930). Data were obtained from 6 administrative databases and linked using generalized software.

Results

After adjustment for age, sex, comorbidity, and diagnostic group, longer time from call to arrival of paramedics at the sending hospital was associated with a shorter length of ICU/CCU stay (rate ratio [RR], 0.91; 95% confidence interval [CI], 0.86-0.97) for survivors and a longer length of hospital (RR, 1.12; 95% CI, 1.05-1.21) and ICU/CCU (RR, 1.14; 95% CI, 1.04-1.25) stay for nonsurvivors in the higher-priority air transport group, and with a slightly shorter length of hospital stay (RR, 0.97; 95% CI, 0.95-0.99) for all patients in the lower-priority air transport group. Longer time spent by paramedics at the sending hospital was associated with a shorter length of hospital stay (RR, 0.79; 95% CI, 0.65-0.96) for survivors in the higher-priority air transport group. Longer time for transport between the sending and receiving hospitals was associated with a longer length of ICU/CCU stay (RR, 1.69; 95% CI, 1.26-2.27) for survivors in the higher-priority air transport group but a slightly shorter length of ICU/CCU stay (RR, 0.97; 95% CI, 0.95-0.99) for all patients in the ground transport group. There were no associations between transport times and hospital mortality.

Conclusions

Transport intervals are independently associated with ICU/CCU and hospital lengths of stay at the receiving hospital for critically ill adults transferred to referral centers.     

Fecal incontinence in hospitalized patients who are acutely ill

BACKGROUND: Information about fecal incontinence experienced by patients in acute-care settings is lacking. The relationship of fecal incontinence to several well-known nosocomial or iatrogenic causes of diarrhea has not been determined. OBJECTIVES: To determine the cumulative incidence of fecal incontinence in hospitalized patients who are acutely ill, and to ascertain the relationship between fecal incontinence and stool consistency, and between diarrhea and two well-known nosocomial or iatrogenic etiologies of diarrhea: Clostridium difficile and tube feeding. The relationship of fecal incontinence and risk factors for diarrhea associated with C. difficile and tube feeding in hospitalized patients was examined. METHODS: Fecal incontinence, stool frequency and consistency, administration of tube feeding and medications, severity of illness, and nutritional data were prospectively recorded in 152 patients on acute or critical care units of a university-affiliated Veterans' Affairs Medical Center. Rectal swabs and stool specimens from patients were obtained weekly for C. difficile culture. C. difficile culture and cytotoxin assay were performed on diarrheal stools. HindIII restriction endonuclease analysis (REA) was used for typing of C. difficile isolates. RESULTS: In this study, 33% (50/152) of the patients had fecal incontinence. The proportion of total surveillance days with fecal incontinence in these patients was 0.50 +/- 0.06. A greater percentage of patients with diarrhea had fecal incontinence than patients without diarrhea (23/53 [43%] vs. 27/99 [27%]; p = 0.04). Incontinence was more frequent in patients with loose/liquid stool consistency than in patients with hard/soft stool consistency (48/50 [96%] vs. 71/100 [71%]; p < 0.001). The proportion of surveillance days with fecal incontinence was related to the proportion of surveillance days with diarrhea (r = 0.69; p < 0.001) and the proportion of surveillance days with loose/liquid stools (r = 0.64; p < 0.001). Multivariate risk factors for fecal incontinence were unformed/loose or liquid consistency of stool (RR = 11.1; 95% confidence interval [CI] = 2.2, 56.7), severity of illness (RR = 5.7; CI = 2.6, 12.3), and age (RR = 1.1; CI = 1, 1.1). CONCLUSIONS: Fecal incontinence is common in hospitalized patients who are acutely ill, but the condition was not associated with any specific cause of diarrhea. Because loose or liquid stool consistency is a risk factor for fecal incontinence, use of treatments that result in a more formed stool may be beneficial in managing fecal incontinence. However, treatments that slow intestinal transit should be avoided in patients with C. difficile-associated diarrhea.     

Echocardiographic prediction of volume responsiveness in critically ill patients with spontaneously breathing activity

Objective In hemodynamically unstable patients with spontaneous breathing activity, predicting volume responsiveness is a difficult challenge since the respiratory variation in arterial pressure cannot be used. Our objective was to test whether volume responsiveness can be predicted by the response of stroke volume measured with transthoracic echocardiography to passive leg raising in patients with spontaneous breathing activity. We also examined whether common echocardiographic indices of cardiac filling status are valuable to predict volume responsiveness in this category of patients. Design and setting Prospective study in the medical intensive care unit of a university hospital. Patients 24 patients with spontaneously breathing activity considered for volume expansion. Measurements We measured the response of the echocardiographic stroke volume to passive leg raising and to saline infusion (500 ml over 15 min). The left ventricular end-diastolic area and the ratio of mitral inflow E wave velocity to early diastolic mitral annulus velocity (E/Ea) were also measured before and after saline infusion. Results A passive leg raising induced increase in stroke volume of 12.5% or more predicted an increase in stroke volume of 15% or more after volume expansion with a sensitivity of 77% and a specificity of 100%. Neither left ventricular end-diastolic area nor E/Ea predicted volume responsiveness. Conclusions In our critically ill patients with spontaneous breathing activity the response of echocardiographic stroke volume to passive leg raising was a good predictor of volume responsiveness. On the other hand, the common echocardiographic markers of cardiac filling status were not valuable for this purpose. This article is discussed in the editorial available at:     

Increased nuclear factor kappa B activation in critically ill patients who die

OBJECTIVES: To determine nuclear factor kappa B (NF-kappa B) activation in mononuclear and neutrophils from critically ill patients and to compare NF-kappa B activation with circulating concentrations of interleukin (IL)-6, IL-8, and soluble intercellular adhesion molecule (sICAM)-1. DESIGN: Observational study. SETTING: University Teaching Hospital, eight-bed intensive care unit in northeast Scotland. PATIENTS: Ten patients admitted to the intensive care unit who fulfilled the criteria for systemic inflammatory response syndrome were studied at 0, 24, 48, and 72 hrs. Six healthy volunteers were also studied. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: NF-kappa B activation was significantly higher in patients compared to healthy volunteers in both neutrophils (p = .001) and mononuclear leukocytes (p = .013). In the six patients who survived to 96 hrs, the level of NF-kappa B activation in mononuclear cells remained constant (p = .9). However, in the four patients who died before 96 hrs, mononuclear cell NF-kappa B activation increased markedly and was significantly higher before death than in those who survived to 96 hrs (p = .0105). NF-kappa B activation in neutrophils similarly remained constant in patients who survived to 96 hrs (p = .4) but did not show the same increase before death. Circulating concentrations of IL-6, IL-8, and sICAM-1 were elevated but were unrelated to leukocyte NF-kappa B activation. CONCLUSIONS: We found NF-kappa B activation in mononuclear and neutrophils in patients with systemic inflammatory response syndrome, which increased markedly before death in mononuclear leukocytes and was not related to plasma IL-6, IL-8, and sICAM-1 concentrations. These data support the need for further study of the role of NF-kappa B activation in mortality from systemic inflammatory response syndrome and sepsis.     

Acquired neuromuscular disorders in critically ill patients: a systematic review

Objective: To summarize the prospective clinical studies of neuromuscular abnormalities in intensive care unit (ICU) patients. Study identification and selection: Studies were identified through MEDLINE, EMBASE, references in primary and review articles, personal files, and contact with authors. Through duplicate independent review, we selected prospective cohort studies evaluating ICU-acquired neuromuscular disorders. Data abstraction: In duplicate, independently, we abstracted key data regarding design features, the population, clinical and laboratory diagnostic tests, and clinical outcomes. Results: We identified eight studies that enrolled 242 patients. Inception cohorts varied; some were mechanically ventilated patients for ≥ 5 days, others were based on a diagnosis of sepsis, organ failure, or severe asthma while others were selected on the basis of exposure to muscle relaxants, or because of participation in muscle biochemistry studies. Weakness was systematically assessed in two of the eight studies, concerning patients with severe asthma, with a reported frequency of 36 and 70 %, respectively. Electrophysiologic and histologic abnormalities consisted of both peripheral nerve and muscle involvement and were frequently reported, even in non-selected ICU patients. In a population of patients mechanically ventilated for more than 5 days, electrophysiologic abnormalities were reported in 76 % of cases. Two studies showed a clinically important increase (5 and 9 days, respectively) in duration of mechanical ventilation and a mortality twice as high in patients with critical illness neuromuscular abnormalities, compared to those without. Conclusions: Prospective studies of ICU-acquired neuromuscular abnormalities include a small number of patients with various electrophysiologic findings but insufficiently reported clinical correlations. Evaluation of risk factors for these disorders and studies examining their contribution to weaning difficulties and long-term disability are needed. Received: 3 April 1998 Accepted: 19 June 1998     

Recognising and managing adult patients who are critically sick

The challenge of recognising the ward-based patient at risk of rapid deterioration is discussed frequently within the literature. As their role enables them to be in constant contact with patients, nurses are in a prime position to identify problems at an early stage with the use of systematic patient assessment. This means appropriate treatment can be initiated quickly, potentially saving the patient's life.     

CONTRA: Hydroxyethyl starch solutions are unsafe in critically ill patients

Purpose  To describe the risk–benefit profile of hydroxyethyl starch (HES). Methods  Narrative review. Results  (1) Efficacy: no single clinical study or systemic review has shown that administration of any HES solution confers a clinically relevant benefit compared to crystalloids in critically ill patients or surgical patients in need of volume replacement. Contrary to beliefs expecting a ratio of 4:1 or more for crystalloid to colloid volume need, recent studies of goal-directed resuscitation observed much lower ratios of between 1 and 1.6. (2) Safety: HES administration is associated with coagulopathy, nephrotoxicity, pruritus and increased long-term mortality. Clinical studies claiming that modern HES 130/0.4 is safe have serious methodological drawbacks and do not adequately address the safety concerns. Conclusions  Given the complete lack of superiority in clinical utility studies and the wide spectrum of severe side effects, the use of HES in the ICU should be stopped. The belief that four times as much crystalloid as colloid fluid volume is needed for successful resuscitation is being seriously questioned. C. Hartog and K. Reinhart contributed equally to this work. The article arguing for this proposition is available at: doi:.     

Bronchoscopy in critically ill patients

Fiberoptic bronchoscopy is a valuable diagnostic and therapeutic tool for use in carefully selected patients with serious pulmonary disease. The authors review the benefits and risks of fiberoptic bronchoscopy and discuss the essentials of nursing care before, during, and after the procedure.     

Tracheostomy in critically ill patients

Tracheostomy is a common critical care procedure in patients with acute respiratory failure who require prolonged mechanical ventilatory support. Tracheostomy usually is considered if weaning from mechanical ventilation has been unsuccessful for 14 to 21 days. A recent clinical trial suggested that early tracheostomy may benefit patients who are not improving and who are expected to require prolonged respiratory support. In this study, early tracheostomy improved survival and shortened duration of mechanical ventilation. Minimally invasive bedside percutaneous tracheostomy was introduced recently as an alternative to the traditional surgical technique. In expert hands, the 2 techniques are equivalent in complications and safety; however, the bedside percutaneous approach may be more cost-effective. Tracheostomy should be considered early (within the first week of mechanical ventilation) in patients with a high likelihood of prolonged mechanical ventilation. Depending on local medical expertise and costs, either the percutaneous or the surgical technique may be used.     

Hyponatremia in critically ill patients

Disorders of sodium and water metabolism are frequently encountered in hospitalized patients. Hyponatremia in critically ill patients can cause significant morbidity and mortality. Inappropriate treatment of hyponatremia can add to the problem. The diagnosis and management of salt and water abnormalities in critically ill patients is often challenging. The increasing knowledge about aquaporins and the role of vasopressin in water metabolism has enhanced our understanding of these disorders. The authors have outlined the general approach to the diagnosis and management of hyponatremia. A systematic approach by clinicians, using a detailed history, physical examination, and relevant diagnostic tests, will assist in efficient management of salt and water problems.     

Myopathy in critically ill patients

OBJECTIVE: To review myopathic changes occurring during intensive care treatment in the light of recent information about manifestation, clinical settings, pathophysiology, and histomorphologic changes. DATA SOURCES: The computerized MEDLINE database, bibliography of pertinent articles, and the author's personal files. STUDY SELECTION: Studies were selected according to their relevance to myopathic complications in critically ill patients. DATA EXTRACTION: All applicable data were extracted. DATA SYNTHESIS: Myopathic changes occur frequently in patients treated in the intensive care unit (ICU). Three main types have been identified: critical illness myopathy, myopathy with selective loss of myosin filaments, and acute necrotizing myopathy of intensive care. These histologic types probably represent variable expressions of a toxic effect not yet identified. Candidates for such myotoxic effects are the mediators of the systemic response in sepsis and high-dose administration of corticosteroids and muscle relaxants. The influence of these latter agents appears to be particularly important in the pathogenesis of myosin loss and myonecrosis. Experimental studies suggest that axonal damage attributable to critical illness neuropathy can be an additional factor triggering myopathies in the ICU. Muscle membrane inexcitability was recently identified as an alternative mechanism of severe weakness in ICU patients. CONCLUSIONS: Myopathic changes are surprisingly frequent in critically ill patients. The clinical importance of this finding is still unknown, but it is likely that weakness caused by myopathy prolongs ICU stay and rehabilitation. Because corticosteroids and muscle relaxants appear to trigger some types of ICU myopathy, they should be avoided or administered at the lowest doses possible. Sepsis, denervation, and muscle membrane inexcitability may be additional factors. Studies addressing the pathophysiology of myopathy in critically ill patients are urgently needed.     

Delirium in critically ill patients

Delirium in the intensive care unit is a serious problem that has recently attracted much attention. User-friendly and reliable tools, such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), offer the clinician the opportunity to identify delirium in patients better. Diagnosis of delirium in a critical care population is often a difficult task because classical psychiatric evaluation is impossible for a number of reasons. The CAM-ICU makes use of nonverbal assessments to evaluate the cardinal features of delirium (i.e. acute or fluctuating onset, inattention, disorganized thinking and altered level of consciousness). Its development for use in the critical care setting represents a significant advance that could lead to better care for such patients.