A cross-sectional survey of critical care services in Sri Lanka: A lower middle-income country

Purpose

To describe the extent and variation of critical care services in Sri Lanka as a first step towards the development of a nationwide critical care unit (CCU) registry.

Materials and Methods

A cross-sectional survey was conducted in all state CCUs by telephone or by visits to determine administration, infrastructure, equipment, staffing, and overall patient outcomes.

Results

There were 99 CCUs with 2.5 CCU beds per 100 000 population and 13 CCU beds per 1 000 hospital beds. The median number of beds per CCU was 5. The overall admissions were 194 per 100 000 population per year. The overall bed turnover was 76.5 per unit per year, with CCU mortality being 17%.Most CCUs were headed by an anesthetist. There were a total of 790 doctors (1.6 per bed), 1 989 nurses (3.9 per bed), and 626 health care assistants (1.2 per bed). Majority (87.9%) had 1:1 nurse-to-patient ratio, although few (11.4%) nurses had received formal intensive care unit training. All CCUs had basic infrastructure (electricity, running water, piped oxygen) and basic equipment (such as electronic monitoring and infusion pumps).

Conclusion

Sri Lanka, a lower middle-income country has an extensive network of critical care facilities but with inequalities in its distribution and facilities.     

Intensive care patients receiving vasoactive medications: A retrospective cohort study

BackgroundVasoactive medications are high-risk drugs commonly used in intensive care units (ICUs), which have wide variations in clinical management.ObjectivesThe aim of this study was to describe the patient population, treatment, and clinical characteristics of patients who did and did not receive vasoactive medications while in the ICU and to develop a predictive tool to identify patients needing vasoactive medications.MethodsA retrospective cohort study of patients admitted to a level three tertiary referral ICU over a 12-month period from October 2018 to September 2019 was undertaken. Data from electronic medical records were analysed to describe patient characteristics in an adult ICU. Chi square and Mann–Whitney U tests were used to analyse data relating to patients who did and did not receive vasoactive medications. Univariate analysis and Pearson's r² were used to determine inclusion in multivariable logistic regression.ResultsOf 1276 patients in the cohort, 40% (512/1276) received a vasoactive medication for haemodynamic support, with 84% (428/512) receiving noradrenaline. Older patients (odds ratio [OR] = 1.02; 95% confidence interval [CI] = 1.01–1.02; p < 0.001) with higher Acute Physiology and Chronic Health Evaluation (APACHE) III scores (OR = 1.04; 95% CI = 1.03–1.04; p < 0.001) were more likely to receive vasoactive medications than those not treated with vasoactive medications during an intensive care admission. A model developed using multivariable analysis predicted that patients admitted with sepsis (OR = 2.43; 95% CI = 1.43–4.12; p = 0.001) or shock (OR = 4.05; 95% CI = 2.68–6.10; p < 0.001) and managed on mechanical ventilation (OR = 3.76; 95% CI = 2.81–5.02; p < 0.001) were more likely to receive vasoactive medications.ConclusionsMechanically ventilated patients admitted to intensive care for sepsis and shock with higher APACHE III scores were more likely to receive vasoactive medications. Predictors identified in the multivariable model can be used to direct resources to patients most at risk of receiving vasoactive medications.     

Repeated sleep‐quality assessment and use of sleep‐promoting interventions in ICU

To describe sleep quality using repeated subjective assessment and the ongoing use of sleep‐promoting interventions in intensive care. It is well known that the critically ill experience sleep disruption while receiving treatment in the intensive care unit. Both the measurement and promotion of sleep is challenging in the complex environment of intensive care unit. Repeated subjective assessment of patients' sleep in the intensive care unit and use of sleep‐promoting interventions has not been widely reported. An observational study was conducted in a 58‐bed adult intensive care unit. Sleep quality was assessed using the Richards‐Campbell Sleep Questionnaire (RCSQ) each morning. intensive care unit audit sleep‐promoting intervention data were compared to data obtained prior to the implementation of a sleep guideline. Patients answered open‐ended questions about the facilitators and deterrents of their sleep in intensive care unit. The sample (n = 50) was predominately male (76%) with a mean age: 62.6±16.9 years. Sleep quality was assessed on 2 days or more for 21 patients. The majority of patients (98%) received sleep‐promoting interventions. Sleep quality had not improved significantly since the guideline was first implemented. The mean Richards‐Campbell Sleep Questionnaire score was 47.9±24.1 mm. The main sleep deterrents were discomfort and noise. Frequently cited facilitators were nothing (i.e. nothing helped) and analgesia. The Richards‐Campbell Sleep Questionnaire was used on repeated occasions, and sleep‐promoting interventions were used extensively. There was no evidence of improvement in sleep quality since the implementation of a sleep guideline. The use of the Richards‐Campbell Sleep Questionnaire for the subjective self‐assessment of sleep quality in intensive care unit patients and the implementation of simple‐promoting interventions by intensive care unit clinicians is both feasible and may be the most practical way to assess sleep in the intensive care unit context.     

Use of 2 % propofol to produce diurnal sedation in critically ill patients

Objective: The assessment of propofol to produce diurnal sedation in critically ill patients Design: Prospective clinical study Setting: Intensive Care Unit, University Hospital Patients and participants: Thirty consecutive patients admitted to the Intensive Care Unit older than 18 years who were expected to be sedated for more than 50 h Interventions: The patients were randomised into two groups. All received sedation with a constant background infusion of morphine and a variable infusion rate of propofol, which was altered hourly to maintain the intended sedation score. The first group received constant light sedation (CLS) over 50 h aiming for a Ramsay score of 2–3. The second group received CLS between 0600 h and 2200 h and additional night sedation (ANS) with propofol between 2200 h and 0600 h, aiming for a sedation score of 4–5. Measurements and results: Patients were studied for 50 h from 1800 h on the first day of admission. Recordings of heart rate, blood pressure, sedation scores and propofol and morphine infusion rates were made hourly. An APACHE II score was recorded for each patient. Sedation scores were analysed by blind visual assessment and cosinor analysis, which is used in chronobiology to examine the correlation of data with a cosine curve. Patients in the ANS group had significantly better rhythmicity of sedation levels using cosinor analysis (r = 26 % v 8 %) p < 0.01. There was no difference between the CLS and ANS groups with respect to age, sex or APACHE II scores. Nine out of 15 patients in the ANS group achieved diurnal sedation. Three patients in the CLS group showed diurnal rhythmicity of sedation, which can be attributed to natural sleep, and had a median APACHE II score of 12. Five patients in the CLS group and three in the ANS group showed a deep constant sedation pattern. They had high APACHE II scores (median 21.5) and an obtunded conscious level on admission due to severe sepsis. Conclusion: Propofol can safely provide diurnal sedation in the critically ill when titrated against the Ramsay score. Sedation levels cannot be manipulated in some severely ill patients. Received: 7 August 1996 Accepted: 16 January 1997     

Instrumentos para valorar el síndrome pos cuidado intensivo,revisión de alcance

IntroductionPost Intensive Care Syndrome is a recently studied syndrome that affects between 50% and 70% of patients admitted to the ICU, its detection is complex due to the great variety of affected components.ObjectiveTo determine the most widely used assessment instruments for the detection of post-intensive care syndrome, according to the evidence in the last 5 years.MethodologyA scoping review was carried out in the databases: Academic Search, ScienceDirect, Scielo, Biblioteca Virtual en Salud, Medline, and Springer Link, with terms «Postintensive care syndrome» and «Post-intensive care syndrome». This review included 22 articles that met the criteria of: research or review typology, English, Spanish or Portuguese language, with access to the full text and published between 2015 and 2020.ConclusionsMost of the instruments used to measure post-intensive care syndrome are divided according to the components of physical affectation (the Medical Research Council scale, the Katz index and the Barthel index); cognitive (Repeatable Battery for the Assessment of Neuropsychological Status, and the Montreal Cognitive Assessment test); and mental (Hospital Anxiety and Depression Scale, Beck's anxiety test, Depression Inventory Second Edition scale and Post Traumatic Stress Syndrome-14 scale). In addition, two tools were found that measure the event in its entirety with its three components, such as the Healthy Aging Brain Care Monitor and the Post-Intensive Care Syndrome Questionnaire.     

International dialogue on end of life: challenges in the UK and USA

Aim: The aim of this paper was to increase international collaboration on end of life care (EoLC) in critical care. Objectives included highlighting key challenges for critical care nurses in EoLC through a transcribed interview between a clinician, an educationalist and a researcher who all hold an EoLC focus. Background: EoLC continues to hold high profile within international health care arenas, including critical care units. Whilst end of life care remains well debated, it still presents many challenges for everyday practitioners. Dialogue with international colleagues and disciplines may provide opportunity for further understanding of this complex and sensitive area. Conclusions: A key issues to arise from this venture of shared learning was that futility of treatment is problematic for all. This is further complicated in the USA where the concept of (family) autonomy strongly shapes EoLC decision making. Relevance to clinical practice: This paper demonstrates that there are opportunities for nurses within health care teams which could be addressed through education and professional development initiatives. Furthermore, knowledge from other disciplines can provide a useful lens through which to improve our understanding of EoLC.     

Oral intake evaluation in patients following critical illness: an ICU cohort study

Timely and adequate nutrition improves health outcomes for the critically ill patient. Despite clinical guidelines recommending early oral nutrition, survivors of critical illness experience significant nutritional deficits. This cohort study evaluates the oral nutrition intake in intensive care unit (ICU) patients who have experienced recent critical illness. The oral nutrition intake of a convenience sample of ICU patients post‐critical illness was observed during a 1‐month period. Data pertaining to both the amount of oral nutrition intake and factors impacting optimal oral nutrition intake were collected and analysed. Inadequate oral intake was identified in 62% of the 79 patients assessed (n = 49). This was noted early in the ICU stay, around day 1–2, for most of the patients. A significant proportion (25%) of patients remained in the hospital with poor oral intake that persisted beyond ICU day 5. Unsurprisingly, these were the patients who had longer ICU stays. Critical illness weakness was a factor in the assessment of poor oral intake. To conclude, patients who have experienced critical illness also experience suboptimal oral nutrition. The three key factors that were identified as impacting optimal oral nutrition were early removal of nasogastric tubes, critical illness weakness and poor appetite post‐critical illness. Seven key recommendations are made based on this cohort study. These recommendations are related to patient assessment, monitoring, documentation and future guidelines. Future research opportunities are highlighted, including the investigation of strategies to improve the transition of patients' post‐critical illness to oral nutrition.     

Comparison of two frailty identification tools for critically ill patients: A post-hoc analysis of a multicenter prospective cohort study

PurposeWe aimed to describe the association of two frailty screening tools, the validated Clinical Frailty Scale (CFS) score and the recently described modified Frailty Index (mFI) in critically ill patients.Materials and methodsWe performed a post-hoc analysis of a multicenter cohort of patients admitted to six Canadian Intensive Care Units (ICU) between 2010 and 2011. Frailty was screened using the CFS and the mFI. Concordance between these tools was evaluated, as well as discrimination and predictive ability for clinical outcomes after adjustments.ResultsThe cohort included 421 patients. Prevalence of frailty was 32.8% with the CFS and 39.2% with the mFI. However, concordance between the two tools was low [(intraclass correlation of 0.37; 95% confidence interval [CI] 0.29–0.45) and partial Spearman rank correlation of 0.38 (95% CI 0.29–0.47)]. Hospital and 1-year mortality, as well as dependency after discharge and hospital readmission, were greater for frail compared to non-frail patients screened with the use of both tools.ConclusionWhile the CFS and mFI showed low concordance, both showed good discrimination and predictive validity for hospital mortality. Both tools identify a subgroup of frail patients more likely to have worse clinical outcomes.     

Estreñimiento en una cohorte prospectiva de adultos críticos: porcentaje y motivo de su incidencia

ObjectiveTo assess the incidence and factors associated with constipation in adult critical care patients.DesignProspective cohort study.SettingIntensive care unit (ICU) of a high-complexity hospital from November 2015 to October 2016.PatientsAdults who were hospitalized for at least 72 h in the ICU were followed from their admission to the ICU until their departure.InterventionsNone.Measurements and main resultsIn the 157 patients followed up, the incidence of constipation was 75.8%. The univariate analysis showed that constipated patients were younger, used more sedation and showed more respiratory and postoperative causes for hospitalization, while non-constipated patients were hospitalized more for gastrointestinal reasons. The use of vasoactive substances, mechanical ventilation and haemodialysis was similar between the constipated and non-constipated patients. Multivariate analysis, days of use of docusate + bisacodyl (HR: .79; 95% CI: .65–.96) of omeprazole or ranitidine (HR: .80; 95%CI: .73–.88) and lactulose (HR: .87; 95%CI: .76–.99) were independent protection factors for constipation.ConclusionConstipation has a high incidence among adult critical care patients. Days of drug use acting on the digestive tract (lactulose, docusate + bisacodyl and omeprazole and/or ranitidine) are able to prevent this outcome.     

Correlation of patient-reported outcome measures to performance-based function in critical care survivors: PREDICTABLE

BackgroundEstablishing sequela following critical illness is a public health priority; however, recruitment and retention of this cohort make assessing functional outcomes difficult. Completing patient-reported outcome measures (PROMs) via telephone may improve participant and researcher involvement; however, there is little evidence regarding the correlation of PROMs to performance-based outcome measures in critical care survivors.ObjectivesThe objective of this study was to assess the relationship between self-reported and performance-based measures of function in survivors of critical illness.MethodsThis was a nested cohort study of patients enrolled within a previously published study determining predictors of disability-free survival. Spearman's correlation (r_s) was calculated between four performance-based outcomes (the Functional Independence Measure [FIM], 6-min walk distance [6MWD], Functional Reach Test [FRT], and grip strength) that were collected during a home visit 6 months following their intensive care unit admission, with two commonly used PROMs (World Health Organization Disability Assessment Scale 2.0 12 Level [WHODAS 2.0] and EuroQol-5 Dimension-5 Level [EQ-5D-5L]) obtained via phone interview (via the PREDICT study) at the same time point.ResultsThere were 38 PROMs obtained from 40 recruited patients (mean age = 59.8 ± 16 yrs, M:F = 24:16). All 40 completed the FIM and grip strength, 37 the 6MWD, and 39 the FRT. A strong correlation was found between the primary outcome of the WHODAS 2.0 with all performance-based outcomes apart from grip strength where a moderate correlation was identified. Although strong correlations were also established between the EQ-5D-5L utility score and the FIM, 6MWD, and FRT, it only correlated weakly with grip strength. The EQ-5D overall global health rating only had very weak to moderate correlations with the performance-based outcomes.ConclusionThe WHODAS 2.0 correlated stronger across multiple performance-based outcome measures of functional recovery and is recommended for use in survivors of critical illness.     

The effect of family-authored diaries on posttraumatic stress disorder in intensive care unit patients and their relatives: A randomised controlled trial (DRIP-study)

BackgroundCritical illness and mechanical ventilation may cause patients and their relatives to experience symptoms of posttraumatic stress, anxiety, and depression due to fragmentation of memories of their intensive care unit (ICU) stay. Intensive care diaries authored by nurses may help patients and relatives process the experience and reduce psychological problems after hospital discharge; however, as patients particularly appreciate diary entries made by their relatives, involving relatives in authoring the diary could prove beneficial.ObjectivesThe objective of this study was to explore the effect of a diary authored by a close relative for a critically ill patient.MethodsThe study was a multicenter, block-randomised, single-blinded, controlled trial conducted at four medical-surgical ICUs at two university hospitals and two regional hospitals. Eligible for the study were patients ≥18 years of age, undergoing mechanical ventilation for ≥24 h, staying in the ICU ≥48 h, with a close relative ≥18 years of age. A total of 116 relatives and 75 patients consented to participate. Outcome measures were scores of posttraumatic stress symptoms, anxiety, depression, and health-related quality of life three months after ICU discharge.ResultsRelatives had 26.3% lower scores of posttraumatic stress in the diary group than in the control group (95% confidence interval: 4.8–% to 52.2%). Patients had 11.2% lower scores of posttraumatic stress symptoms in the diary group (95% confidence interval: −15.7% to 46.8%). There were no differences between groups in depression, anxiety, or health-related quality of life.ConclusionA diary written by relatives for the ICU patient reduced the risk of posttraumatic stress symptoms in relatives. The diary had no effect on depression, anxiety, or health-related life quality. However, as the diary was well received by relatives and proved safe, the diary may be offered to relatives of critically ill patients during their stay in the ICU.     

Zur Entwicklung der Intensivmedizin in Österreich — mit besonderer Berücksichtigung der internistischen Intensivmedizin

Ohne Zusammenfassung

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Care of the multiple organ donor

Successful organ transplantation offers patients with end stage organ failure the chance of a normal life. The recognition of brain death allowed the use of beating heart donors and this has enabled multiple organ procurement from a single donor. Suitable patients with severe brain injury resulting in brain death, who may be potential organ donors, are to be found on both neurosurgical and general intensive care units. The pathophysiological results of brain death are similar, irrespective of the underlying cause. Severe brain injury may result in the loss of temperature regulation, and the development of diabetes insipidus and cardiovascular instability. The management of brain injury before death often results in abnormalities of fluid balance, due to fluid restriction and diuretic therapy. Other problems such as acute endocrine failure and the impact of their correction on ultimate organ function remains to be elucidated. Good donor maintenance in the intensive care unit and operating theatre is essential if optimal function of the transplanted organ is to occur.