Incidence of and risk factors for post–intensive care syndrome among Chinese respiratory intensive care unit patients: A cross-sectional,prospective study

BackgroundPatients transferred from the respiratory intensive care unit (ICU) can experience post–intensive care syndrome (PICS), which comprises cognitive, psychological, and physical disorders that seriously affect the quality of life. Therefore, it was necessary to explore the incidence of and the risk factors for PICS among respiratory ICU patients.ObjectivesThis study evaluated PICS among respiratory ICU patients and explored the risk factors for PICS.MethodsThis cross-sectional, prospective study was performed at one hospital in China. Using convenience sampling, 125 respiratory ICU patients from August 2018 to June 2019 were recruited for the study. The Mini-Mental State Examination, Confusion Assessment Method for the Intensive Care Unit, Hospital Anxiety and Depression Scale, Medical Research Council Scale, activities of daily living scale, Pittsburgh Sleep Quality Index, and the 14-item fatigue scale were used to comprehensively assess the patients' cognitive status, psychological status, and physiological status when entering the ICU and 2 weeks after leaving the ICU. Factors affecting PICS were measured using researcher-created questionnaires of patients’ general information and disease-related information.ResultsFifteen patients were lost to follow-up. Fifty-nine patients had PICS (incidence rate, 53.6%). Logistic regression showed that risk factors for PICS were age, invasive mechanical ventilation, noninvasive ventilator-assisted ventilation, and coronary heart disease (P < 0.05).ConclusionThe PICS incidence was high. Older age, longer invasive mechanical ventilation times, longer noninvasive ventilator times, and coronary heart disease were risk factors for PICS. ICU medical workers in China should pay more attention on PICS, know the risk factors, and implement preventive measures.     

Pharmacokinetic–pharmacodynamic study of itraconazole in patients with fungal infections in intensive care units

Severely ill patients in intensive care units (ICU) are frequently at risk of developing fungal infections. Itraconazole (ITCZ), a triazole antifungal agent, is used for the treatment of aspergillosis, candidiasis, and cryptoccosis. The present retrospective pharmacokinetic–pharmacodynamic (PK–PD) analysis was designed to find any factors affecting clinical outcome of ITCZ treatment, and was performed to evaluate the appropriateness of the current dosage regimen in ICU patients. All of the patients admitted to Aichi Medical University Hospital ICU in 2008 who were treated with ITCZ injections for fungal infections were included in the study. After outcomes had been classified as cure or failure, a PK–PD analysis was performed. In addition, the probability of PD target attainment was assessed using a Monte Carlo simulation. Ten patients were enrolled in the study. Satisfactory outcomes were obtained in 4 of the 10 patients. No significant differences in the area under the 24-h curve (AUC_0–24), peak concentrations and trough concentrations were observed between the two groups. However, it was observed that the higher the AUC_0–24, the better the outcome. Moreover, our results showed that additional dosage is needed to attain a sufficiently high AUC_0–24/MIC in about 20% of patients. Our retrospective study is the first to show that it is important to consider the host’s condition when ITCZ is administered, especially in ICU patients. The present findings are also useful for optimizing the individual dosage of ITCZ based on AUC_0–4 for the treatment of patients infected with Candida spp.     

Risk factors for post–intensive care syndrome: A systematic review and meta-analysis

ObjectiveThe objective of this study was to identify the risk factors for each area of post–intensive care syndrome (PICS) and to determine their effect size.Review method usedThis study used systematic review and meta-analysis.Data sourcesPubMed, CINAHL, EMBASE, PsycINFO, and Cochrane Library were searched.Review methodsEighty-nine studies were selected for the review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PICS areas and risk factors reported in the individual studies were reviewed and categorised. We used the Newcastle–Ottawa Scale to evaluate the quality of studies. The effect size of each risk factor was calculated as odds ratio (OR).ResultsThere were 33 mental health studies, 15 cognitive impairment studies, 32 physical impairment studies, eight studies on two areas, and one study on all three areas. Sixty risk factors were identified, including 33 personal and 27 intensive care unit (ICU)–related factors. Significant risk factors for mental health included female sex (odds ratio [OR] = 3.37, 95% confidence interval [CI]: 1.12–10.17), previous mental health problems (OR = 9.45, 95% CI: 2.08–42.90), and negative ICU experience (OR = 2.59, 95% CI: 2.04–3.28). The only significant risk factor for cognitive impairment was delirium (OR = 2.85, 95% CI: 1.10–7.38). Significant risk factors for physical impairment included older age (OR = 2.19, 95% CI: 1.11–4.33), female sex (OR = 1.96, 95% CI: 1.32–2.91), and high disease severity (OR = 2.54, 95% CI: 1.76–3.66).ConclusionsAlthough PICS is a multidimensional concept, each area has been studied separately. Significant risk factors for PICS included older age, female sex, previous mental health problems, disease severity, negative ICU experience, and delirium. To prevent PICS, the multidisciplinary team should pay attention to modifiable risk factors such as delirium and patients’ ICU experience.     

Screening tools for post–intensive care syndrome and post-traumatic symptoms in intensive care unit survivors: A scoping review

BackgroundEvidence suggests that intensive care unit (ICU) survivors often suffer long-term complications such as post–intensive care syndrome (PICS) and post-traumatic stress disorder (PTSD) from critical illness and ICU stay. PICS and PTSD affect both ICU survivors and their families, which overburdens the healthcare systems. Lack of evidence on the comparative psychometric properties of assessment tools is a major barrier in evidence-based screening for post-ICU symptomatology and health-related quality of life.ObjectivesWe aimed to identify existing tools for screening PTSD and PICS in ICU survivors and their families and to examine evidence on the validity, reliability, sensitivity, and specificity of existing tools, as reflected in published peer-reviewed studies.MethodA scoping review based on literature searches (CINAHL, MEDLINE, EMBASE, PsycINFO, Scopus, Health and Psychosocial Instruments, Dissertations and Theses Global, and Google Scholar) and predefined eligibility criteria was conducted according to current scoping review guidelines.FindingsWe identified 44 studies reporting on the development and assessment of psychometric properties of PICS/PTSD in ICU survivors or families globally. We identified five tools addressing all three aspects of PICS manifestations, one tool for both physical and mental aspects of PICS, and fivefive tools for quality-of-life assessment in ICU survivors. Altogether, 25 tools assess only one aspect of PICS: five for cognitive impairment, seven for physical impairment, and 13 for mental health impairment and PTSD in ICU survivors. However, only two tools were found for PICS-family assessment. Other findings include (i) unclear validity and often limited feasibility of tools, (ii) low diagnostic accuracy of cognitive assessment tools, and (iii) evidence of appropriate psychometric properties and feasibility of psychological health assessment tools.ConclusionThese results have implications for the selection and implementation of the assessment methods as a means for promoting meaningful patient-centred clinical outcomes to minimise long-term sequelae, reduce the rate of rehospitalisation, and optimise recovery after ICU discharge.     

Socioeconomic status,severity of disease and level of family members’ care in adult surgical intensive care patients: the prospective ECSSTASI study

Background  

Low socioeconomic status (SES) is associated with increased mortality from cardiovascular disease, cancer and trauma. However, individual-level prospective data on SES in relation to health outcomes among critically ill patients admitted to intensive care units (ICU) are unavailable.     

Outcomes of daytime nurse practitioner–staffed versus resident-staffed nonsurgical intensive care units: A retrospective observational study

BackgroundRapid developments in medical care—such as monitoring devices, medications, and working hours restrictions for intensive care personnel—have dramatically increased the demand for intensive care physicians. Therefore, nurse practitioner (NP)–staffed care is becoming increasingly important. This study was aimed to compare the outcomes of daytime NP-staffed and daytime resident-staffed nonsurgical intensive care units (ICU).MethodsWe retrospectively assessed patients admitted to a nonsurgical ICU from March 2017 to December 2017. We collected basic patient data, including age, sex, admission diagnosis, transferring unit, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Primary endpoints were ICU mortality, hospital mortality, and 30-day mortality. Secondary endpoints were 48-h readmission, discharge to nonhome locations, and lengths of ICU and hospital stay.ResultsA total of 838 subjects were analysed: 334 subjects in the NP-staffed group and 504 in the resident-staffed group. The NP-staffed group was more likely to come from inpatient units (38.3% vs 16.5% for resident-staffed group; p < 0.001) and had lower disease severity (APACHE II score, 13.9 ± 8.4 vs 15.1 ± 8.2 for resident-staffed group; p = 0.047). After adjusting for age, sex, location before ICU admission, APACHE II score, and significantly different basic characteristics, there were no differences in ICU mortality, hospital mortality, or 30-day mortality between the two groups. Secondary analysis showed the NP-staffed group had a lower discharge rate to nonhome locations (2.1% vs 6.3%; p = 0.023) and shorter hospital stay (12.1 ± 14.1 vs 14.2 ± 14.3 days; p = 0.015).ConclusionsWe observed no difference in mortality between daytime NP-staffed and resident-staffed nonsurgical ICUs. Daytime NP-staffed care is an effective, safe, feasible method for staffing nonsurgical ICUs.     

Host–pathogen interactions and prognosis of critically ill immunocompetent patients with pneumococcal pneumonia: the nationwide prospective observational STREPTOGENE study

Purpose

To assess the relative importance of host and bacterial factors associated with hospital mortality in patients admitted to the intensive care unit (ICU) for pneumococcal community-acquired pneumonia (PCAP).

Methods

Immunocompetent Caucasian ICU patients with PCAP documented by cultures and/or pneumococcal urinary antigen (UAg Sp) test were included in this multicenter prospective study between 2008 and 2012. All pneumococcal strains were serotyped. Logistic regression analyses were performed to identify risk factors for hospital mortality.

Results

Of the 614 patients, 278 (45%) had septic shock, 270 (44%) had bacteremia, 307 (50%) required mechanical ventilation at admission, and 161 (26%) had a diagnosis based only on the UAg Sp test. No strains were penicillin-resistant, but 23% had decreased susceptibility. Of the 36 serotypes identified, 7 accounted for 72% of the isolates, with different distributions according to age. Although antibiotics were consistently appropriate and were started within 6 h after admission in 454 (74%) patients, 116 (18.9%) patients died. Independent predictors of hospital mortality in the adjusted analysis were platelets?≤?100 × 10⁹/L (OR, 7.7; 95% CI, 2.8–21.1), McCabe score?≥?2 (4.58; 1.61–13), age?>?65 years (2.92; 1.49–5.74), lactates?>?4 mmol/L (2.41; 1.27–4.56), male gender and septic shock (2.23; 1.30–3.83 for each), invasive mechanical ventilation (1.78; 1–3.19), and bilateral pneumonia (1.59; 1.02–2.47). Women with platelets?≤?100 × 10⁹/L had the highest mortality risk (adjusted OR, 7.7; 2.8–21).

Conclusions

In critically ill patients with PCAP, age, gender, and organ failures at ICU admission were more strongly associated with hospital mortality than were comorbidities. Neither pneumococcal serotype nor antibiotic regimen was associated with hospital mortality.

     

Effect of human immunodeficiency virus on intensive care unit outcome of patients with Guillain-Barré syndrome

OBJECTIVES: The primary objective of this study was to investigate the effect of human immunodeficiency virus (HIV) infection on the outcome of patients admitted to the intensive care unit (ICU) with severe Guillain-Barré syndrome (GBS) requiring mechanical ventilation. A secondary objective was to compare the clinical and laboratory features of HIV-seronegative and HIV-seropositive patients admitted to the ICU with severe GBS. DESIGN: Retrospective chart review. SETTING: Two tertiary, academic hospitals in Johannesburg, South Africa. MATERIALS AND METHODS: The case records of all patients admitted to the ICU with GBS between January 1995 and June 2002 were reviewed. Patients were included if their HIV status was known and if they had clinical features, electrophysiologic studies, and cerebrospinal fluid analyses consistent with GBS. Demographic data, days in ICU, days ventilated, CD4 T-lymphocyte counts (in the HIV group), cerebrospinal studies, infection rate, and mortality data were analyzed. RESULTS: A total of 13 patients met the inclusion criteria: seven were HIV seronegative and six were HIV seropositive. The median age in the HIV group was 34.5 yrs, compared with 47 yrs in the non-HIV group. There was no significant difference between the two groups in days spent in the ICU or days ventilated. There were no significant differences in cerebrospinal studies, electrophysiologic studies, and blood culture-positive infections between the two groups. All patients received intravenous immunoglobulin (0.4 g/kg/day for 5 days). There was one death in the HIV-seropositive group and no deaths in the HIV-seronegative group. The median CD4 T-lymphocyte count in the HIV group was 322.5 x 106 cells/L. CONCLUSION: HIV is commonly associated with GBS in South Africa. The ICU outcome in patients with HIV-associated GBS is similar to HIV-seronegative patients, particularly if the CD4 T-lymphocyte count is greater than 200 x 106 cells/L at admission.     

The use of Instanyl® in the treatment of breakthrough pain in cancer patients: a 3-month observational,prospective, cohort study

Purpose

Instanyl® (intranasal fentanyl spray) is a novel treatment for breakthrough pain (BTP) in cancer patients. It has shown a rapid onset of pain relief in clinical trials. This study examines the use of Instanyl® in real-life settings.

Methods

A 3-month observational, prospective, cohort study of cancer patients with BTP receiving Instanyl® (50, 100, or 200 μg) under routine clinical practice. Data were collected at three time points corresponding with routine clinic visits – baseline, Week 4, and Week 13. Primary outcomes: success of titration and maintenance dose after titration. Secondary outcomes: change in maintenance dose of Instanyl® and level of background pain medication; Brief Pain Inventory—Short Form (BPI-SF) and Patient Treatment Satisfaction Scale (PTSS) scores; adverse drug reactions (ADRs).

Results

Titration with Instanyl® was successful in 84.5 % of 309 patients; most patients were titrated at the lowest dose (50 μg). The majority showed no change in maintenance dose, with little change in the level of background pain medication. BPI-SF and PTSS scores significantly improved from baseline to Week 4. The main reason for terminating Instanyl® was death, as expected due to the underlying disease; incidence of ADRs was low and no fatal ADRs were reported.

Conclusions

In a real-life group of cancer patients with disease progression, Instanyl® was titrated successfully at doses <200 μg in the majority of patients, requiring only one dose, with no further change in maintenance dose. Pain severity, impact of pain on daily life, and treatment satisfaction significantly improved with Instanyl® treatment. No unexpected ADRs occurred.     

Guillain–Barre´ syndrome patient's satisfaction with physiotherapy: A two-part observational study

The purpose of this observational study was to assess Guillain–Barre´ syndrome (GBS) patients' satisfaction with physiotherapy in the acute and sub-acute setting, and provide an overview of inpatient case management, including the number of complications. Twenty-seven patients admitted to Sir Charles Gairdner Hospital (SCGH) with GBS between 1 May 2005 and 30 April 2010 were considered for inclusion. Nineteen patients consented and a waiver of consent was granted for four other patients. Data were collected from case-note audit (n?=?23) and telephone survey (n?=?19) during June and July 2011. Participants receiving physiotherapy (n?=?16) reported they were satisfied with management (87%), treatment frequency (88%), duration (94%), and timetabling (81%) of treatment and the professionalism and rapport (100%) of physiotherapists. Median length of hospital stay was 20 days (range 5–198) for 23 participants. Physiotherapists documented patient assessment within 2 days from admission (range 1–5). First functional improvements were documented on day 6 (median, range 2–34). Physiotherapists were most commonly first to mobilize patients to sit, stand, transfer, and walk (83%, 82%, 81%, and 90%, respectively). Twenty patients (87%) developed complications during their hospital stay, the most common being low back pain (61%). This study has demonstrated that GBS patients were satisfied with care provided by physiotherapy.     

The diagnostic value of serum leptin monitoring and its correlation with tumor necrosis factor-α in critically ill patients: a prospective observational study

Introduction  

Severe infection and sepsis are common causes of morbidity and mortality. Early diagnosis in critically ill patients is important to reduce these complications. The present study was conducted to determine the role of serum leptin at early diagnosis and differentiation between patients with manifestations of systemic inflammatory response syndrome (SIRS) and those with sepsis in patients suffering from a broad range of diseases in the intensive care unit (ICU) and its correlation with other biomarkers, such as C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α).     

The effects of the reorganisation of an intensive care unit due to COVID-19 on nurses’ wellbeing: An observational cross-sectional study

ObjectivesTo evaluate the effects of the reorganisation of an intensive care unit for COVID-19 patients in the context of the SARS-CoV-2 pandemic on wellbeing perceived by nurses.MethodsAn observational cross-sectional study was conducted to evaluate wellbeing perceived by nurses who during the study were on duty in the COVID-19 intensive care unit. The “Covid-19-Nurse Well-being at Work (NWB) scale” questionnaire consisting of 72 items divided into 13 sections, was validated and used to collect data.ResultsThe level of wellbeing perceived by the nurses was very good (4.77; SD 0.83). Differences in the of level of perceived wellbeing were found for “years of experience” and the various levels of competence. We found a positive correlation between “female gender” and “nurses’ togetherness and collaboration”, a negative correlation between “male gender” and “satisfactory practical organisation of work, and a negative correlation between “work experience” and the overall “level of wellbeing at work.ConclusionsThe reorganisation had positive effects in terms of wellbeing perceived by the nurses. The factors that contributed mostly to the perception of wellbeing were in the area of “support”, “communication, and “socializing with colleagues”. It is appropriate to consider “gender differences”, “work experience” and “levels of competence” when implementing this type of reorganisation to respond to a pandemic or a health emergency.     

Advanced lung cancer patients’ experience with continuity of care and supportive care needs

As cancer care becomes increasingly complex, the ability to coordinate this care is more difficult for health care providers, patients and their caregivers alike. Despite the widely recognized need for improving continuity and coordination of care, the relationship of continuity of care with patient outcomes has yet to be elucidated. Our study’s main finding is that the Continuity and Coordination subscale of the widely used Picker System of Ambulatory Cancer Care Survey is able to distinguish between lung cancer patients with unmet supportive care needs and those without. Specifically, this study shows a new association between this widely implemented continuity and coordination survey and the ‘psychological needs’ domain, as well as the ‘health system and information’ domains of supportive care needs. The finding provides support for the idea that interventions to improve continuity may impact tangible indicators of patient care such as supportive care needs being met. The study focuses attention on continuity of care as an important aspect of optimizing outcomes in cancer care.     

Outcome of patients with injection drug use–associated endocarditis admitted to an intensive care unit

Purpose

The purpose of this study was to study the outcome of patients with injection drug use–associated infective endocarditis (IDU-IE) admitted to an intensive care unit (ICU).

Material and Methods

A retrospective review of medical records of 33 consecutive patients with IDU-IE admitted to ICU was conducted.

Results

Main indications for admission to ICU were as follows: severe sepsis or septic shock (36%), respiratory failure (33%), and neurologic deterioration (18%). Staphylococcus aureus was found in 94% of patients, and 15% had polymicrobial infection. Fifteen (45%) patients had septic emboli to 1 or more organs, including 12 (36%) to lungs and 7 (21%) to central nervous system. In-hospital mortality was 27%, and in univariate analysis, previous history of endocarditis (odds ratio [OR], 11.2; P = .03), respiratory failure (OR, 7; P = .03), neurologic failure (OR, 6.25; P = .03), and high Acute Physiology and Chronic Health Evaluation II (OR, 1.21; P = .016) and Sequential Organ Failure Assessment scores (OR, 1.25; P = .01) increased risk of death. By multivariate logistic regression analysis, previous history of endocarditis and high Acute Physiology and Chronic Health Evaluation II score were independently associated with poor survival.

Conclusions

Complicated IDU-IE necessitating admission to ICU is associated with high mortality. In addition to consequences of sepsis, septic embolization to central nervous system and lungs contributes to development of organ failure. Increased severity of illness and prior history of endocarditis are associated with poor outcome.     

Psychological determinants of quality of life in patients with whiplash associated disorders–a prospective study

Purpose. To evaluate whether psychological factors and personality traits influence recovery in terms of quality of life in patients with subacute whiplash associated disorders (WAD).

Method. The data was obtained from a randomized controlled trial (RCT) on 47 patients. The patients completed measures of pain intensity, affective dimension of pain, pain location, psychological stress, heightened somatic awareness, depression, catastrophizing, self-efficacy, fear of movement (re)injury, and physical disability. After three months of physiotherapy interventions, the outcome of quality of life was measured with the Short Form Health survey (SF-12). All variables were entered in a multiple regression analysis, after controlling for age and sex.

Results. Forty patients (85%) completed the trial. The self-efficacy scale (SES) was the only variable in the model that significantly explained the fraction of the SF12-score. The correlation between the SES and SF-12 was B = 0.64 (p < 0.01), and the adjusted R² was 0.40 (p < 0.05), which means that 40% of the variation in the SF12 outcomes was explained by the SES.

Conclusion. In order to improve health-related quality of life in patients with WAD, the present study stresses the importance of targeting self-efficacy. A special effort should be made to enhance these beliefs in the rehabilitation process.     

An observational study of upper gastrointestinal bleeding in intensive care units: is Helicobacter pylori the culprit?

OBJECTIVE: Upper gastrointestinal bleeding (UGIB) related to stress ulcers was formerly a fearsome complication of intensive care. The incidence of this event has decreased over the years. However, the morbidity, mortality, and causes of UGIB, particularly the etiologic role of Helicobacter pylori infection, are still controversial. Therefore, we prospectively assessed the incidence of UGIB in the intensive care unit (ICU) and evaluated the role of H. pylori infection. DESIGN: A prospective observational study followed by a case-control study. SETTING: Seven ICUs in the Paris area, five of them located in teaching hospitals. PATIENTS: All patients admitted consecutively to seven ICUs during a 1-year period were monitored for signs of clinically relevant UGIB. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Only cases of endoscopically confirmed UGIB were analyzed. Patients whose hemorrhage originated from the stomach and/or duodenum were tested for H. pylori infection, by means of serology, histologic examination, and stool antigen detection. The possible association between H. pylori and UGIB was examined in a case-control study. Twenty-nine of the 4,341 patients admitted to the seven ICUs during the study period had clinically relevant, endoscopically confirmed UGIB (incidence, 0.67%; 95% confidence interval, 0.56%-0.77%). Ulcers were most frequently observed endoscopically. Patients who bled had a higher Simplified Acute Physiology Score (SAPS II) at admission (mean +/- sd, 47 +/- 14 vs. 36 +/- 28; p < .001). Despite a higher in-ICU mortality rate among patients who bled (73% vs. 16%; p < .001), death was never due to bleeding. H. pylori infection was more frequent in patients who bled than in matched controls (36% vs. 16%; p = .04). CONCLUSIONS: Clinically relevant, endoscopically confirmed UGIB is a rare event in the ICU setting and tends to occur in severely ill patients. H. pylori infection is more frequent in patients with gastroduodenal hemorrhage than in nonbleeding patients.