Identification of distinct subgroups of breast cancer patients based on self-reported changes in sleep disturbance

Purpose

The purposes of this study were to identify distinct subgroups of patients based on self-reported sleep disturbance prior to through 6 months after breast cancer surgery and evaluate for differences in demographic, clinical, and symptom characteristics among these latent classes.

Methods

Women (n?=?398) who underwent unilateral breast cancer surgery were enrolled prior to surgery. Patients completed measures of functional status, sleep disturbance (i.e., General Sleep Disturbance Scale (GSDS); higher scores indicate higher levels of sleep disturbance), fatigue, attentional fatigue, depressive symptoms, and anxiety prior to surgery and monthly for 6 months.

Results

Three distinct classes of sleep disturbance trajectories were identified using growth mixture modeling. The high sustained class (55.0%) had high and the low sustained class (39.7%) had low GSDS scores prior to surgery that persisted for 6 months. The decreasing class (5.3%) had high GSDS score prior to surgery that decreased over time. Women in the high sustained class were significantly younger, had more comorbidity and poorer function, and were more likely to report hot flashes compared to the low sustained class. More women who underwent mastectomy or breast reconstruction were in the decreasing class. Decreasing and high sustained classes reported higher levels of physical fatigue, attentional fatigue, depressive symptoms, and anxiety compared to the low sustained class.

Conclusions

A high percentage of women has significant sleep disturbance prior to surgery that persists during subsequent treatments (i.e., radiation therapy and chemotherapy). Clinicians need to perform routine assessments and initiate appropriate interventions to improve sleep prior to and following surgery.     

Effect of colleague and coworker abuse on family physicians in Canada

Objective

To assess the effects of physician-colleague and coworker abuse on family physicians in Canada.

Design

A mixed-methods, bilingual study that included surveys and telephone interviews.

Setting

Canada.

Participants

Family physicians in active practice who were members of the College of Family Physicians of Canada in 2009.

Methods

Surveys were mailed to a random sample of family physicians (N = 3802), and 37 family physicians who had been abused in the past year participated in telephone interviews.

Main findings

A total of 770 surveys (20%) were completed. A small number of respondents reported having been subjected to abuse by physician colleagues (9%) or coworkers (6%) in the previous month. Many of the respondents reported that the same physician colleagues or coworkers were repeat abusers. More than three-quarters (77%) of the physician-colleague abusers were men, whereas more than three-quarters (77%) of the other coworker abusers were women. Interviewed family physicians described feeling humiliated and unappreciated, and developed symptoms of anxiety or depression. As a result of the abuse, some family physicians terminated their employment or refused to work in certain environments. The most striking effect of this abuse was that respondents reported losing confidence in their professional abilities and skills.

Conclusion

Although only a small number of family physicians experience abuse by physician colleagues and other coworkers, the effects can be considerable. Victims reported a loss of confidence in their clinical abilities and some subsequently were faced with mental health issues.     

Sleepless nights in the ICU: the awaken family

Having a loved-one in the ICU is a traumatic experience for family members that can lead to a cluster of psychological complications, recently defined as post-intensive care family syndrome. In a previous issue of Critical Care, Day and colleagues stressed the severe sleep disturbance and fatigue experienced by a majority of ICU patient family members. However, despite this burden being well characterised, the best preventive coping strategy remains undetermined.In a previous issue of Critical Care, Day and colleagues [1] investigated sleep, anxiety and fatigue in family members of patients admitted to the ICU. Using validated self-report tools, the majority of family members of ICU patients reported moderate to severe sleep disturbance and fatigue. This newly recognized family burden may have dramatic consequences as sleep deprivation may interfere with their decision-making and care-taking abilities. These findings emphasize the immense turmoil experienced by family members and suggest that surrogate decision makers could be temporarily incompetent, raising issues about the shared decision-making model [2].Perhaps, more so in intensive care than in other medical disciplines, relatives of critically ill patients playa key role during the long ICU course. They frequently play both caregiver and surrogate decision maker roles. Thus, the patient-physician relationship moves to a family-patient-physician-nurse relationship, making the ICU environment quite unique. Among stakeholders, each party may suffer from stress. Neglected for too long, the damaging psychological consequences of an ICU stay on physicians [3] and on relatives are now better characterized [4]. As underlined by Day and colleagues [1], family members of ICU patients have frequent intense sleep deprivation and are exposed to symptoms of anxiety and depression that could lead to psychiatric diseases such as panic disorder, post-traumatic stress disorder [5], or complicated grief [6].As the aging population requires more critical care and ICU mortality decreases, family members will increasingly have opportunities to share in the care of their loved one [7]. Managing a relative''s burden remains the main issue. We advocate that our ICUs have enough resources to prevent post-ICU burden. This requires communication strategies and improved behaviours. For instance, seeing family members sleeping in the waiting room is, unfortunately, a frequent occurrence for night shift clinicians [8]. We have to admit that most of our ICUs do not offer accommodation for family members, and a change in ICU design that integrates night accommodation for family members is warranted and unrealistic at the same time. Instead, several simple measures, mostly based on improving communication strategies and on family-centred ICU organization, have shown an ability to improve family burden. To be effective, interventions must be feasible, easy to reproduce, accessible, resource minimising, and easily integrated at the bedside. Informative hand-outs for educating families about critical illness and intensive therapies, as well as proactive and effective communication strategies fulfil these requirements [9]. As suggested by 25% of the respondents in the study of Day and colleagues [1], improving the frequency and the quality of the information related to their loved ones could allow them to leave the hospital during the night and improve the quality of their sleep. Simple changes in ICU structure, including but not limited to open visitation policies for families and rooms dedicated to family conferences, could also possibly have a beneficial impact on family anxiety and satisfaction. Additionally, flexible visitation in the ICU setting provides the family with opportunities to maintain social links (child care, professional activities, social commitments, and soon). These changes could enable them to manage daily life while allowing them breathing space. Free visitation policies are also an opportunity to alleviate their guilt. This is particularly true for families with ICU patients with lengthy ICU stays.Multiple risk factors of family burden have been identified, and preventative strategies rest on multifaceted programs. Thus, rather than a single intervention, we believe implementing multiple simple and accessible interventions (that is, family information leaflets, routine family conferences, daily family rounds, structured information, unrestricted visiting hours, regular nurse-family-physician meetings, family care specialist nurses, and so on) may prove effective in preventing post-intensive care family syndrome. We are at a time where a qualitative ''care bundle'' for family members has to be implemented in our daily practice. In addition to reducing sedation intensity in critically ill patients, we should find ways to provide healing information to family members and encourage them to safeguard their sleeping time. Studies to improve sleep quality in family members are warranted.     

Intensive care unit depth of sleep: proof of concept of a simple electroencephalography index in the non-sedated

Introduction

Intensive care unit (ICU) patients are known to experience severely disturbed sleep, with possible detrimental effects on short- and long- term outcomes. Investigation into the exact causes and effects of disturbed sleep has been hampered by cumbersome and time consuming methods of measuring and staging sleep. We introduce a novel method for ICU depth of sleep analysis, the ICU depth of sleep index (IDOS index), using single channel electroencephalography (EEG) and apply it to outpatient recordings. A proof of concept is shown in non-sedated ICU patients.

Methods

Polysomnographic (PSG) recordings of five ICU patients and 15 healthy outpatients were analyzed using the IDOS index, based on the ratio between gamma and delta band power. Manual selection of thresholds was used to classify data as either wake, sleep or slow wave sleep (SWS). This classification was compared to visual sleep scoring by Rechtschaffen & Kales criteria in normal outpatient recordings and ICU recordings to illustrate face validity of the IDOS index.

Results

When reduced to two or three classes, the scoring of sleep by IDOS index and manual scoring show high agreement for normal sleep recordings. The obtained overall agreements, as quantified by the kappa coefficient, were 0.84 for sleep/wake classification and 0.82 for classification into three classes (wake, non-SWS and SWS). Sensitivity and specificity were highest for the wake state (93% and 93%, respectively) and lowest for SWS (82% and 76%, respectively). For ICU recordings, agreement was similar to agreement between visual scorers previously reported in literature.

Conclusions

Besides the most satisfying visual resemblance with manually scored normal PSG recordings, the established face-validity of the IDOS index as an estimator of depth of sleep was excellent. This technique enables real-time, automated, single channel visualization of depth of sleep, facilitating the monitoring of sleep in the ICU.     

Sleep continuity: a new metric to quantify disrupted hypnograms in non-sedated intensive care unit patients

Introduction

Sleep in intensive care unit (ICU) patients is severely altered. In a large proportion of critically ill patients, conventional sleep electroencephalogram (EEG) patterns are replaced by atypical sleep. On the other hand, some non-sedated patients can display usual sleep EEG patterns. In the latter, sleep is highly fragmented and disrupted and conventional rules may not be optimal. We sought to determine whether sleep continuity could be a useful metric to quantify the amount of sleep with recuperative function in critically ill patients with usual sleep EEG features.

Methods

We retrospectively reanalyzed polysomnographies recorded in non-sedated critically ill patients requiring non-invasive ventilation (NIV) for acute hypercapnic respiratory failure. Using conventional rules, we built two-state hypnograms (sleep and wake) and identified all sleep episodes. The percentage of time spent in sleep bouts (<10 minutes), short naps (>10 and <30 minutes) and long naps (>30 minutes) was used to describe sleep continuity. In a first study, we compared these measures regarding good (NIV success) or poor outcome (NIV failure). In a second study performed on a different patient group, we compared these measurements during NIV and during spontaneous breathing.

Results

While fragmentation indices were similar in the two groups, the percentage of total sleep time spent in short naps was higher and the percentage of sleep time spent in sleep bouts was lower in patients with successful NIV. The percentage of total sleep time spent in long naps was higher and the percentage of sleep time spent in sleep bouts was lower during NIV than during spontaneous breathing; the level of reproducibility of sleep continuity measures between scorers was high.

Conclusions

Sleep continuity measurements could constitute a clinically relevant and reproducible assessment of sleep disruption in non-sedated ICU patients with usual sleep EEG.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-014-0628-4) contains supplementary material, which is available to authorized users.     

Prevalence of iron deficiency on ICU discharge and its relation with fatigue: a multicenter prospective study

Introduction

Prevalence of iron deficiency (ID) at intensive care (ICU) admission is around 25 to 40%. Blood losses are important during ICU stay, leading to iron losses, but prevalence of ID at ICU discharge is unknown. ID has been associated with fatigue and muscular weakness, and may thus impair post-ICU rehabilitation. This study assessed ID prevalence at ICU discharge, day 28 (D28) and six months (M6) after and its relation with fatigue.

Methods

We conducted this prospective, multicenter observational study at four University hospitals ICUs. Anemic (hemoglobin (Hb) less than 13 g/dL in male and less than 12 g/dL in female) critically ill adult patients hospitalized for at least five days had an iron profile taken at discharge, D28 and M6. ID was defined as ferritin less than 100 ng/L or less than 300 ng/L together with a transferrin saturation less than 20%. Fatigue was assessed by numerical scale and the Multidimensional Fatigue Inventory-20 questionnaire at D28 and M6 and muscular weakness by a hand grip test at ICU discharge.

Results

Among 107 patients (men 77%, median (IQR) age 63 (48 to 73) years) who had a complete iron profile at ICU discharge, 9 (8.4%) had ID. At ICU discharge, their hemoglobin concentration (9.5 (87.7 to 10.3) versus 10.2 (92.2 to 11.7) g/dL, P =0.09), hand grip strength (52.5 (30 to 65) versus 49.5 (15.5 to 67.7)% of normal value, P =0.61) and visual analog scale fatigue scale (57 (40 to 80) versus 60 (47.5 to 80)/100, P =0.82) were not different from non-ID patients. At D28 (n =80 patients) and M6 (n =78 patients), ID prevalence increased (to 25 and 35% respectively) while anemia prevalence decreased (from 100% to 80 and 25% respectively, P <0.0001). ID was associated with increased fatigue at D28, after adjustment for main confounding factors, including anemia (regression coefficient (95%CI), 3.19 (0.74 to 5.64), P =0.012). At M6, this association disappeared.

Conclusions

The prevalence of ID increases from 8% at discharge to 35% six months after prolonged ICU stay (more than five days). ID was associated with increased fatigue, independently of anemia, at D28.     

Characterisation of sleep in intensive care using 24-hour polysomnography: an observational study

Introduction

Many intensive care patients experience sleep disruption potentially related to noise, light and treatment interventions. The purpose of this study was to characterise, in terms of quantity and quality, the sleep of intensive care patients, taking into account the impact of environmental factors.

Methods

This observational study was conducted in the adult ICU of a tertiary referral hospital in Australia, enrolling 57 patients. Polysomnography (PSG) was performed over a 24-hour period to assess the quantity (total sleep time: hh:mm) and quality (percentage per stage, duration of sleep episode) of patients'' sleep while in ICU. Rechtschaffen and Kales criteria were used to categorise sleep. Interrater checks were performed. Sound pressure and illuminance levels and care events were simultaneously recorded. Patients reported on their sleep quality in ICU using the Richards Campbell Sleep Questionnaire and the Sleep in Intensive Care Questionnaire. Data were summarised using frequencies and proportions or measures of central tendency and dispersion as appropriate and Cohen''s Kappa statistic was used for interrater reliability of the sleep data analysis.

Results

Patients'' median total sleep time was 05:00 (IQR: 02:52 to 07:14). The majority of sleep was stage 1 and 2 (medians: 19 and 73%) with scant slow wave and REM sleep. The median duration of sleep without waking was 00:03. Sound levels were high (mean Leq 53.95 dB(A) during the day and 50.20 dB(A) at night) and illuminance levels were appropriate at night (median <2 lux) but low during the day (median: 74.20 lux). There was a median 1.7 care events/h. Patients'' mean self-reported sleep quality was poor. Interrater reliability of sleep staging was highest for slow wave sleep and lowest for stage 1 sleep.

Conclusions

The quantity and quality of sleep in intensive care patients are poor and may be related to noise, critical illness itself and treatment events that disturb sleep. The study highlights the challenge of quantifying sleep in the critical care setting and the need for alternative methods of measuring sleep. The results suggest that a sound reduction program is required and other interventions to improve clinical practices to promote sleep in intensive care patients.

Trial registration

Australian New Zealand clinical trial registry (http://www.anzctr.org.au/): ACTRN12610000688088.     

An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12-month follow-up study

Introduction

The socio-economic impact of critical illnesses on patients and their families in Europe has yet to be determined. The aim of this exploratory study was to estimate changes in family circumstances, social and economic stability, care requirements and access to health services for patients during their first 12 months after ICU discharge.

Methods

Multi-center questionnaire-based study of survivors of critical illness at 6 and 12 months after ICU discharge.

Results

Data for 293 consenting patients who spent greater than 48 hours in one of 22 UK ICUs were obtained at 6 and 12 months post-ICU discharge. There was little evidence of a change in accommodation or relationship status between pre-admission and 12 months following discharge from an ICU. A negative impact on family income was reported by 33% of all patients at 6 months and 28% at 12 months. There was nearly a 50% reduction in the number of patients who reported employment as their sole source of income at 12 months (19% to 11%) compared with pre-admission. One quarter of patients reported themselves in need of care assistance at 6 months and 22% at 12 months. The majority of care was provided by family members (80% and 78%, respectively), for half of whom there was a negative impact on employment. Amongst all patients receiving care, 26% reported requiring greater than 50 hours a week. Following discharge, 79% of patients reported attending their primary care physician and 44% had seen a community nurse. Mobility problems nearly doubled between pre-admission and 6 months (32% to 64%). Furthermore, 73% reported moderate or severe pain at 12 months and 44% remained significantly anxious or depressed.

Conclusions

Survivors of critical illness in the UK face a negative impact on employment and commonly have a care requirement after discharge from hospital. This has a corresponding negative impact on family income. The majority of the care required is provided by family members. This effect was apparent by 6 months and had not materially improved by 12 months. This exploratory study has identified the potential for a significant socio-economic burden following critical illness.     

Developing an early screening instrument for predicting psychological morbidity after critical illness

Introduction

Guidelines recommend follow-up for patients after an intensive care unit (ICU) stay. Methods for identifying patients with psychological problems after intensive care would be of value, to optimize treatment and to improve adequate resource allocation in ICU follow-up of ICU survivors. The aim of the study was to develop a predictive screening instrument, for use at ICU discharge, to identify patients at risk for post-traumatic stress, anxiety or depression.

Methods

Twenty-one potential risk factors for psychological problems - patient characteristics and ICU-related variables - were prospectively collected at ICU discharge. Two months after ICU discharge 252 ICU survivors received the questionnaires Post-Traumatic Stress Symptom scale -10 (PTSS-10) and Hospital Anxiety and Depression Scale (HADS) to estimate the degree of post-traumatic stress, anxiety and depression.

Results

Of the 150 responders, 46 patients (31%) had adverse psychological outcome, defined as PTSS-10 >35 and/or HADS subscales ≥8. After analysis, six predictors were included in the screening instrument: major pre-existing disease, being a parent to children younger than 18 years of age, previous psychological problems, in-ICU agitation, being unemployed or on sick-leave at ICU admission and appearing depressed in the ICU. The total risk score was related to the probability for adverse psychological outcome in the individual patient. The predictive accuracy of the screening instrument, as assessed with area under the receiver operating characteristic curve, was 0.77. When categorizing patients in three risk probability groups - low (0 to 29%), moderate (30 to 59%) high risk (60 to 100%), the actual prevalence of adverse psychological outcome in respective groups was 12%, 50% and 63%.

Conclusion

The screening instrument developed in this study may aid ICU clinicians in identifying patients at risk for adverse psychological outcome two months after critical illness. Prior to wider clinical use, external validation is needed.     

Visitation policies and practices in US ICUs

Introduction

Prior reports suggest that restrictive ICU visitation policies can negatively impact patients and their loved ones. However, visitation practices in US ICUs, and the hospital factors associated with them, are not well described.

Methods

A telephone survey was made of ICUs, stratified by US region and hospital type (community, federal, or university), between 2008 and 2009. Hospital characteristics were self-reported and included the hospitals'' bed number, critical care unit number, and presence of ICU leadership. Hospital and ICU visitation restrictions were based on five criteria: visiting hours; visit duration; number of visitors; age of visitors; and membership in the patient''s immediate family. Hospitals or ICUs without restrictions had open visitation policies; those with any restriction had restrictive policies.

Results

The study surveyed 606 hospitals in the Northeast (17.0%), Midwest (26.2%), South (36.6%), and West (20.1%) regions; most were community hospitals (n = 401, 66.2%). The mean hospital size was 239 ± 217 beds; the mean percentage of ICU beds was 11.6% ± 13.4%. Hospitals often had restrictive hospital (n = 463, 76.4%) and ICU (n = 543, 89.6%) visitation policies. Many ICUs had ≥ 3 restrictions (n = 375; 61.9%), most commonly related to visiting hours and visitor number or age. Nearly all ICUs allowed visitation exceptions (n = 474; 94.8%). ICUs with open policies were more common in hospitals with < 150 beds. Among restrictive ICUs, the bed size, hospital type, number of critical care units, and ICU leadership were not associated with the number of restrictions. On average, hospitals in the Midwest had the least restrictive policies, while those in the Northeast had the most restrictive.

Conclusion

In 2008 the overwhelming majority of US ICUs in this study had restrictive visitation policies. Wide variability in visitation policies suggests that further study into the impact of ICU visitations on care and outcomes remains necessary to standardize practice.     

Do Circadian Preferences Influence the Sleep Patterns of Night Shift Drivers?

Objective

The objective of this study was to analyze the effect of individual circadian preferences of drivers with fixed night work schedules on sleep patterns.

Subjects and Methods

A total of 123 professional drivers, 32 indifferent preference drivers and 91 morning preference drivers of an intermunicipality and interstate bus transportation company were evaluated. All drivers underwent polysomnographic recordings after their shifts. Furthermore, they filled out a questionnaire that contained sociodemographic and health questions. The Horne and Östberg questionnaire was used to assess the subjects'' morningness-eveningness preference.

Results

The mean age was 42.54 ± 6.98 years and 82 (66.66%) of the drivers had worked for ≥15 years. A significant effect on rapid eye movement (REM) was observed in the morning preference drivers. They showed an increased sleep latency and an REM sleep percentage of 5% of the total REM time. This reveals a significant effect on sleep architecture associated with work time.

Conclusion

The drivers reported that morning preference had a significant effect on their sleep pattern indicating less REM sleep and longer REM sleep latency in the morning preference group. Thus, it is important to evaluate interactions between individual aspects of health and other parameters, such as sleep quality and work organizational factors, to promote night shift workers'' health and well-being.Key Words: Circadian rhythm, Shift work, Sleep     

Hip fracture prevention strategies in long-term care: a survey of Canadian physicians' opinions

OBJECTIVE

To garner Canadian physicians’ opinions on strategies to reduce hip fractures in long-term care (LTC) facilities, focusing on secondary prevention.

DESIGN

A cross-sectional survey using a mailed, self-administered, written questionnaire.

SETTING

Canada.

PARTICIPANTS

Family physician members of the Ontario Long-Term Care Association (n = 165) and all actively practising geriatricians registered in the Canadian Medical Directory (n = 81).

MAIN OUTCOME MEASURES

The strength of recommendations for fracture-reduction strategies in LTC and barriers to implementing these strategies.

RESULTS

Of the 246 physicians sent the questionnaire, 25 declined study materials and were excluded. Of the 221 remaining, 120 responded for a response rate of 54%. About two-thirds of respondents were family physicians (78 of 120) and the rest were mostly geriatricians. Most respondents strongly recommended the following secondary prevention strategies for use in LTC after hip fracture: calcium, vitamin D, oral aminobisphosphonates, physical therapy, and environmental modification (such as handrails). Most respondents either did not recommend or recommended limited use of etidronate, intravenous bisphosphonates, calcitonin, raloxifene, testosterone (for hypogonadal men), and teriparatide. Postmenopausal hormone therapy was discouraged or not recommended by most respondents. Support was mixed for the use of hip protectors, B vitamins, and folate. Barriers to implementation identified by most respondents included a lack of strong evidence of hip fracture reduction (for B vitamins and folate, cyclic etidronate, and testosterone), side effects (for postmenopausal hormone therapy), poor compliance (for hip protectors), and expense (for intravenous bisphosphonates and teriparatide). Some respondents cited side effects or poor compliance as barriers to using calcium and potent oral bisphosphonates.

CONCLUSION

Canadian physicians favour the use of calcium, vitamin D, potent oral bisphosphonates, physical therapy, and evironmental modifications for LTC residents after hip fracture. Further study at the clinical and administrative levels is required to find ways to overcome the specific barriers to implementation and effectiveness of these interventions.     

Selected Musculoskeletal and Performance Characteristics of Members of a Women's Professional Football Team: Application of a Pre-participation Examination

Background

Although it is common practice to administer pre-participation examinations (PPE) of athletes prior to training, there are no clearly established formats. Elements integral to the PPE fall within the scope of physical therapist practice, and are often categorized as a form of primary prevention for musculoskeletal disorders as defined in the Guide to Physical Therapist Practice.

Purpose

The purpose of this study is to describe the design and implementation of a PPE for a women''s professional (gridiron) football team. The results and findings from this PPE provide one of the first musculoskeletal profiles and information about selected physical characteristics from members of a female professional football team.

Methods

Players from the Kentucky Karma women''s football team, a member of the National Women''s Football League (NWFA), volunteered to participate in a PPE. Of twenty-five eligible team members, thirteen consented to participate. The PPE consisted of a health history questionnaire, a musculoskeletal screening, and a series of physical performance and agility tests.

Results

The players'' average (± SD) age, height, weight, body mass index (BMI), and body fat percentage were 29.6 (± 5.6) yrs., 1.66 (± .05) m, 66.8 (± 12.6) kg, 24.1 (± 3.7), and 27.4 (± 6.6) %, respectively. Commonly reported injuries were similar to those reported in men''s collegiate football.

Conclusion

This is one of the first papers to report on a model PPE for a women''s professional football team. Future research is needed to establish a standard PPE, recognize common injuries, and develop prevention strategies unique to women''s professional football.     

Diagnosis and management of temperature abnormality in ICUs: a EUROBACT investigators' survey

Introduction

Although fever and hypothermia are common abnormal physical signs observed in patients admitted to intensive care units (ICU), little data exist on their optimal management. The objective of this study was to describe contemporary practices and determinants of management of temperature abnormalities among patients admitted to ICUs.

Methods

Site leaders of the multi-national EUROBACT study were surveyed regarding diagnosis and management of temperature abnormalities among patients admitted to their ICUs.

Results

Of the 162 ICUs originally included in EUROBACT, responses were received from 139 (86%) centers in 23 countries in Europe (117), South America (8), Asia (5), North America (4), Australia (3) and Africa (2). A total of 117 (84%) respondents reported use of a specific temperature threshold in their ICU to define fever. A total of 14 different discrete levels were reported with a median of 38.2°C (inter-quartile range, IQR, 38.0°C to 38.5°C). The use of thermometers was protocolized in 91 (65%) ICUs and a wide range of methods were reportedly used, with axillary, tympanic and urinary bladder sites as the most common as primary modalities. Only 31 (22%) of respondents indicated that there was a formal written protocol for temperature control among febrile patients in their ICUs. In most or all cases practice was to control temperature, to use acetaminophen, and to perform a full septic workup in febrile patients and that this was usually directed by physician order. While reported practice was to treat nearly all patients with neurological impairment and most patients with acute coronary syndromes and infections, severe sepsis and septic shock, this was not the case for most patients with liver failure and fever.

Conclusions

A wide range of definitions and management practices were reported regarding temperature abnormalities in the critically ill. Documenting temperature abnormality management practices, including variability in clinical care, is important to inform planning of future studies designed to optimize infection and temperature management strategies in the critically ill.     

Quality of blood culture testing - a survey in intensive care units and microbiological laboratories across four European countries

Introduction

Blood culture (BC) testing before initiation of antimicrobial therapy is recommended as a standard of care in international sepsis guidelines and has been shown to reduce intensive care unit (ICU) stay, antibiotic use, and costs in hospitalized patients. Whereas microbiological laboratory practice has been highly standardized, shortfalls in the preanalytic procedures in the ICU (that is indication, time-to-incubation, blood volume and numbers of BC sets) have a significant effect on the diagnostic yield. The objective of this study was to gain insights into current practices regarding BC testing in intensive care units.

Methods

Qualitative survey, data collection by 138 semi-structured telephone interviews in four European countries (Italy, UK, France and Germany) between September and November 2009 in 79 clinical microbiology laboratories (LABs) and 59 ICUs.

Results

Whereas BC testing is expected to remain the gold standard for sepsis diagnostics in all countries, there are substantial differences regarding preanalytic procedures. The decision to launch BC testing is carried out by physicians vs. ICU nurses in the UK in 92 vs. 8%, in France in 75 vs. 25%, in Italy in 88 vs. 12% and in Germany in 92 vs. 8%. Physicians vs. nurses collect BCs in the UK in 77 vs. 23%, in France in 0 vs. 100%, in Italy in 6 vs. 94% and in Germany in 54 vs. 46%. The mean time from blood collection to incubation in the UK is 2 h, in France 3 h, in Italy 4 h, but 20 h in German remote LABs (2 h in in-house LABs), due to the large number of remote nonresident microbiological laboratories in Germany. There were major differences between the perception of the quality of BC testing between ICUs and LABs. Among German ICU respondents, 62% reported that they have no problems with BC testing, 15% reported time constraints, 15% cost pressure, and only 8% too long time to incubation. However, the corresponding LABs of these German ICUs reported too many false positive results due to preanalytical contaminations (49%), insufficient numbers of incoming BC sets (47%), long transportation time (41%) or cost pressure (18%).

Conclusions

There are considerable differences in the quality of BC testing across European countries. In Germany, time to incubation is a considerable problem due to the increasing number of remote LABs. This is a major issue of concern to physicians aiming to implement sepsis guidelines in the ICUs.     

Estimation of optic nerve sheath diameter on an initial brain computed tomography scan can contribute prognostic information in traumatic brain injury patients

Introduction

The aim of this study was to evaluate the prognostic value of optic nerve sheath diameter (ONSD) measured on the initial brain computed tomography (CT) scan for intensive care unit (ICU) mortality in severe traumatic brain injury (TBI) patients.

Methods

A prospective observational study of all severe TBI patients admitted to a neurosurgical ICU (over a 10-month period). Demographic and clinical data and brain CT scan results were recorded. ONSD for each eye was measured on the initial CT scan. The group of ICU survivors was compared to non-survivors. Glasgow Outcome Scale (GOS) was evaluated six months after ICU discharge.

Results

Seventy-seven patients were included (age: 43 ± 18; 81% males; mean Injury Severity Score: 35 ± 15; ICU mortality: 28.5% (n = 22)). Mean ONSD on the initial brain CT scan was 7.8 ± 0.1 mm in non-survivors vs. 6.8 ± 0.1 mm in survivors (P < 0.001). The operative value of ONSD was a good predictor of mortality (area under the curve: 0.805). An ONSD cutoff ≥ 7.3 had a sensitivity of 86.4% and a specificity of 74.6% and was independently associated with mortality in this population (adjusted odds ratio 95% confidence interval: 22.7 (3.2 to 159.6), P = 0.002). There was a relationship between initial ONSD values and six-month GOS (P = 0.03).

Conclusions

ONSD measured on the initial brain CT scan is independently associated with ICU mortality rate (when ≥ 7.3 mm) in severe TBI patients.     

Nasal continuous positive airway pressure improves myocardial perfusion reserve and endothelial-dependent vasodilation in patients with obstructive sleep apnea

Background

Obstructive sleep apnea (OSA) has been associated with cardiovascular disease (CVD), but whether OSA is an independent risk factor for CVD is controversial. The purpose of this study is to determine if patients with OSA have subclinical cardiovascular disease that is detectable by multi-modality cardiovascular imaging and whether these abnormalities improve after nasal continuous positive airway pressure (nCPAP).

Results

Of the 35 consecutive subjects with newly diagnosed moderate to severe OSA recruited from the Stanford Sleep Disorders Clinic, 20 patients were randomized to active vs. sham nCPAP. Active nCPAP was titrated to pressures that would prevent sleep disordered breathing based on inpatient polysomnography. OSA patients had baseline vascular function abnormalities including decreased myocardial perfusion reserve (MPR), brachial flow mediated dilation (FMD) and nitroglycerin-induced coronary vasodilation. Patients randomized to active nCPAP had improvement of MPR (1.5 ± 0.5 vs. 3.0 ± 1.3, p = 0.02) and brachial FMD (2.5% ± 5.7% vs. 9.0% ± 6.5%, p = 0.03) after treatment, but those randomized to sham nCPAP showed no significant improvement. There were no significant changes seen in chamber sizes, systolic and diastolic function, valvular function and coronary vasodilation to nitroglycerin.

Conclusions

Patients with moderate to severe OSA had decreased MPR and brachial FMD that improved after 3 months of nCPAP. These findings suggest that relief of apnea in OSA may improve microvascular disease and endothelial dysfunction, which may prevent the development of overt cardiovascular disease. Further study in a larger patient population may be warranted.     

Hydroxyethyl starch in severe sepsis: end of starch era?

Expanded abstract

Citation

Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, Åneman A, Madsen KR, Møller MH, Elkjær JM, Poulsen LM, Bendtsen A, Winding R, Steensen M, Berezowicz P, Søe-Jensen P, Bestle M, Strand K, Wiis J, White JO, Thornberg KJ, Quist L, Nielsen J, Andersen LH, Holst LB, Thormar K, Kjældgaard AL, Fabritius ML, Mondrup F, Pott FC, Møller TP, Winkel P, Wetterslev J; 6S Trial Group; Scandinavian Critical Care Trials Group: Hydroxyethyl starch 130/0.42 versus Ringer''s acetate in severe sepsis. N Engl J Med 2012, 367:124-34.

Background

Hydroxyethyl starch (HES) is widely used for fluid resuscitation in ICUs, but its safety and efficacy have not been established in patients with severe sepsis.

Methods

Objective

To assess the effects of HES 130/0.4 compared with a balanced crystalloid solution on mortality and end-stage kidney failure in patients with severe sepsis.

Design

Multicenter, parallel-group, blinded, randomized clinical trial, in patients with severe sepsis.

Interventions

Patients with severe sepsis admitted to the ICU received fluid resuscitation with either 6% HES 130/0.42 (Tetraspan) or Ringer''s acetate at a dose of up to 33 ml per kilogram of ideal body weight per day.

Results

Of the 804 patients who underwent randomization, 798 were included in the modified intention-to-treat population. The two intervention groups had similar baseline characteristics. At 90 days after randomization, 201 of 398 patients (51%) assigned to HES 130/0.42 had died, as compared with 172 of 400 patients (43%) assigned to Ringer''s acetate (relative risk, 1.17; 95% confidence interval (CI), 1.01 to 1.36; P = 0.03); 1 patient in each group had end-stage kidney failure. In the 90-day period, 87 patients (22%) assigned to HES 130/0.42 were treated with renal replacement therapy versus 65 patients (16%) assigned to Ringer''s acetate (relative risk, 1.35; 95% CI, 1.01 to 1.80; P = 0.04), and 38 patients (10%) and 25 patients (6%), respectively, had severe bleeding (relative risk, 1.52; 95% CI, 0.94 to 2.48; P = 0.09). The results were supported by multivariate analyses, with adjustment for known risk factors for death or acute kidney injury at baseline.

Conclusions

Patients with severe sepsis assigned to fluid resuscitation with HES 130/0.42 had an increased risk of death at day 90 and were more likely to require renal replacement therapy compared with those receiving Ringer''s acetate.