Quality of life after intensive care in trauma patients

Published studies and our own preliminary results show that Intensive Care Unit (ICU) patients admitted after severe trauma, all report reduced quality of life (QOL) after discharge. In contrast to other ICU patients, this reduction is decreased by time, but does not seem to reach pre-ICU levels. Interventions to improve this situation have not been documented. This should be a high priority aspect for all health personnel caring for patients surviving severe trauma.     

外科重症监护室老年患者的多导睡眠图分析

目的 评估外科重症监护室(surgical intensive care unit,SICU)非机械通气老年患者术后的睡眠质量和睡眠结构. 方法 采用澳大利亚生产的Compumedics Siesta多导睡眠图(polysomnography,PSG)监测系统,分析50例SICU术后当晚的非机械通气老年患者(病例组)和40例非手术的老年体检者(对照组)的PSG. 结果 与对照组比较,病例组的术后睡眠总时间减少[289.5 min(147.5～398.8 min)比218.4 min(125.3～345.7 min)] (P＜0.05),睡眠效率低[48.2％ (24.6％～66.5％)比36.3％(20.8％～57.6％)](P＜0.05);病例组术后睡眠以1期睡眠为主[67.3％(21.6％～78.3％)],对照组睡眠以2期睡眠为主[59.6％(18.2％～73.2％)];与对照组比较,病例组术后深睡眠显著减少[18.3％(4.1％～20.9％)比7.9％(0～11.4％)](P＜0.05),所有患者缺乏快速眼动睡眠(rapid eye movement,REM),72％(36例)患者缺乏慢波睡眠(slow wave sleep,sws),对照组只有6例缺乏REM,5例缺乏SWS.与对照组比较,病例组的术后睡眠更破碎,夜间睡眠觉醒更频繁[9.1次/h(4.8～24.3次/h)比20.5次/h(8.8～32.2次/h)](P＜0.01). 结论 术后老年患者容易出现睡眠障碍和睡眠剥夺,表现为睡眠总时间不足、深睡眠缺乏、睡眠破碎、频繁觉醒.     

Quality of life after intensive care

An important aspect of effectiveness of intensive care services is change in the quality of life of survivors after critical illness. A questionnaire was complied using established methods for assessment of quality of life and sent to all known survivors of a regional intensive care unit. Each patient's quality of life was then quantified using disability categories. The results show that patients with a good premorbid quality of life suffered a significant decline after critical illness. Similar important decreases in quality of life were found in younger patients and trauma victims. Quality of life may be a valuable consideration in determining the appropriateness of intensive care management.     

Quality of life, morbidity, and mortality after surgical intensive care: a follow-up study of patients treated for abdominal sepsis in the surgical intensive care unit.

OBJECTIVE: To evaluate the long-term outcome of patients treated in the surgical intensive care unit (SICU) for abdominal sepsis. DESIGN: Retrospective study. SETTING: University hospital, Sweden. SUBJECTS: 210 consecutive patients treated for abdominal sepsis in the SICU at Lund University Hospital during the period January 1983 to December 1995. MAIN OUTCOME MEASURES: Background information, morbidity, and mortality. Follow-up of surviving patients with interview and completion of a quality of life (QoL) assessment. Information collected postmortem from the registers of the Swedish National Board of Health and Welfare. RESULTS: At follow-up, 45 patients of the 151 who survived the initial hospital stay had died, 41 were lost to follow up and 16 chose not to participate in the study; 49 patients completed the study. Median QoL scores were significantly impaired (p < 0.01) although subjective QoL did not change significantly. In-hospital mortality was 28% (59/210) and total mortality over the time period 50% (104/210). CONCLUSION: Most patients who survived after treatment of abdominal sepsis in the SICU regained good health and their functional status was restored. Subjective QoL remained unchanged.     

Quality of life before and after intensive care

Quality of life is often thought to be poor before and after intensive care unit admission. The aim of this study was to investigate changes in quality of life before and after intensive care. A prospective cohort study of 300 consecutive patients admitted to intensive care was performed in a Scottish Teaching Hospital. Quality of life was assessed premorbidly and 3, 6 and 12 months after intensive care admission for surviving patients using SF-36 as well as EQ-5D scores at 12 months. The median value for age was 60.5 years and for APACHE II score, 18. The mean length of stay was 6.7 days. SF-36 physical component scores decreased from premorbid values at 3 months (p = 0.05) and then returned to premorbid values at 12 months (p < 0.001). The mean physical scores were below the population norm at all time points but the mean mental scores were similar or higher than these population norms. Patients who died after intensive care discharge had lower quality of life scores than did survivors (all p < 0.01). Poor premorbid quality of life was demonstrated and appears to reduce after ICU discharge. For survivors there was a slow increase in physical quality of life to premorbid levels by the end of the first year but these remained lower than in the general population. ICU patients experience a considerable longer-term burden of ill health.     

Physician-accompanied transport of surgical intensive care patients

During a one-year period, 107 critically ill adult patients were transferred by a physician-accompanied transport system (PATS). Most patients required both tracheal intubation (82 per cent) and mechanical ventilation (71 per cent), while continuous vasopressor support was required in 27 per cent of transfers. Patients were classified as either potential organ donors (n = 21) or nondonor patients (n = 86). Nondonor patients had a mean time of patient transfer documented from the initial telephone contact to final arrival of the patient in the ICU of 345 ± 221 min (range 65-1350 min); the mean time the patients were out-of-hospital was 73 ± 58 min (range 5-330 min); the average distance travelled by the patient and PATS was 342 ± 692 km (range 1-4000 km), ultimate nonsurvivors of ICU admission (36 per cent) had shorter out-of-hospital times, shorter travel distances, and increased interventional support, as assessed by the Therapeutic Intervention Scoring System applied over the telephone and prior to departure at the referring hospital. Significant interventions were undertaken by PATS in 23 per cent of the nondonor patients prior to departure. During the transport process, there was at least a seven per cent morbidity (arrhythmia, hypotension, and vehicular difficulties) and a 0.9 mortality rate. We conclude that PATS offered significant advantages to this patient population through its ability to maintain acceptable morbidity and mortality rates white transferring patients over long distances and for prolonged periods of time.     

Plasma fibronectin and associated variables in surgical intensive care patients

An acute depletion of plasma fibronectin or FN has been observed in critically ill, surgical, or trauma patients, but there is little information on the relationships between FN levels and the final outcome in such cases, and on the simultaneous behaviour of other serum proteins. The daily values of FN, antithrombin III, IgG, C3, prealbumin, and transferrin were monitored in 98 intensive care patients after major elective surgery or trauma. According to their clinical course, they were divided retrospectively into three groups. Group A (33 patients) had sepsis. Group B (31 patients) had nonseptic complications, and group C (34 patients) had no complications in the ICU. The individual, nadir levels of FN, AT III, prealbumin, and transferrin were lower (p less than 0.01) in the septic group A than in B and C. Within the septic group, the nadir levels of AT III, but not those of FN, were lower (p less than 0.01) in the 14 nonsurvivors than in the 19 survivors. The FN and AT III levels had returned at least temporarily to the normal range in the six ultimate fatalities from sepsis who survived for more than two weeks. In the septic group, transferrin showed the highest percentages of actually subnormal levels and differed from FN in this respect with p less than 0.05. Furthermore, all six proteins showed a significant overall pattern (p less than 0.01) of parallel variations. The results confirm other reports on the behavior of fibronectin in septic patients as a group, but it was not informative as to the individual outcome, and its reduction might be viewed as part of a general plasma protein depletion associated with acute septic disease. This pattern is probably attributable to a combination of intravascular consumption and an overall excess of protein catabolism over synthesis.     

Antibiotic choices in surgical intensive care unit patients.

Antibiotics have dramatically changed the care of the critically ill patient over the last 60 years. Patients with complex physiological conditions present with infectious processes requiring the effective use of antimicrobial drugs. In many situations, the inability to eradicate the infectious process is complicated by the progressive development of resistance among the causative organisms. Systemic antibiotic prophylaxis is warranted only for the prevention of wound infections. Regimens in these cases should use large doses of nontoxic antibiotics covering the spectrum of organisms likely to contaminate the wound. The duration of wound prophylaxis should be short, essentially covering only the period of active wound closure; this is usually less than 24 hours. Prevention of most other infections in the ICU depends on the recognition and correction of the various disturbances of host defenses. Topical antibiotic therapy may reduce the level of colonization for a few specific types of infection. Initial empiric antibiotic therapy should be started for clear indications. The antibiotics chosen should be those most likely to be effective against the probable organisms, those which have the lowest toxicity, and those with the smallest likelihood of inducing multiresistance. They must be adjusted promptly based on the microbiologic sensitivities observed. The realization that the physiology of critical illness may alter the normal relations between drug dosages and the tissue antibiotic levels obtained mandates a different approach to the treatment of these patients. The drug volumes of distribution are generally markedly expanded in these patients. Furthermore, these patients require high tissue antibiotic concentrations to improve the chances for successful therapy. Thus, the antibiotics selected must be capable of providing these levels without significant toxicity to the host. Therapy should be continued based on the clinical response observed. Premature cessation of effective therapy often results in relapse.     

Real-time controlled pleural puncture in surgical intensive care patients

The sensitivity of ultrasonographic diagnosis of pleural fluid accumulations and the value of ultrasonography guided thoracentesis were studied prospectively. 110 patients were investigated after abdominal operation and chest trauma. Most investigations were performed in a half sitting position. Pleural fluid of clinical relevance diagnosed by real time ultrasonography was treated by thoracentesis under ultrasonographic guidance in 38 cases. The amount of aspirated fluid ranged from 150 ml to 1350 ml. Sensitivity of the method was 97.1%, complication rate was 2.6%. From our view ultrasonography guided thoracentesis represents the method of choice in critically ill and immobile patients.     

Long-term survival and quality of life in cardiac surgical patients with prolonged intensive care unit length of stay

BACKGROUND: Patients with prolonged intensive care unit (ICU) stays after cardiac operations are labor intensive and expensive. We sought to determine whether exhaustive ICU efforts result in survival or quality-of-life benefits and whether outcome could be predicted. METHODS: We retrospectively analyzed all adult cardiac surgical patients in 1998 for ICU stays more than 14 days. Data were analyzed to create multiple organ dysfunction scores (MODS, range 0 to 24) and hospital charges. Follow-up was conducted 1 and 2 years apart for survival and quality-of-life evaluation. RESULTS: Forty-nine patients remained in the ICU more than 14 days, comprising 3.8% of our patients but 28% of total ICU bed time. This population had a 28.5% hospital mortality, which was greater than those in the ICU less than 14 days (5.3%, p < 0.05). By 2 years, 22 of the 35 discharged patients were alive, 16 of whom had a normal quality of life. Patients alive at 2 years had lower MODS at day 14 than those who died (2.6 +/- 1.4 versus 5.5 +/- 3.8; p < 0.005) as well as lower hospital costs ($223,000 +/- $128,000 versus $306,000 +/- $128,000; p < 0.05). No patient with an MODS of at least 6 at day 14 survived. CONCLUSIONS: Patients remaining in the ICU for more than 14 days suffer a higher mortality at greater expense. A MODS at day 14 may help predict those who will not enjoy long-term survival and thus aid in the decision to terminate care.     

Quality of life after a stay in the intensive care unit

The study of quality of life is a critical indicator in evaluating the care of patients in intensive care. This must be measured to detect signs of psychological and physical sequelae and adapt patient support accordingly.     

Analysis of life expectancy and living status of elderly patients surviving a burn injury

This study evaluates the long-term outcome of elderly patients discharged from hospital after a burn injury. Ninety-three patients over the age of 60 years, admitted to a regional burn center, were included in the study from January 1981 to January 1986. The in-hospital mortality rate was 49.4%. Patients' living status was graded according to dependency: 47% of patients were reduced to a more dependent living status on discharge, and 36% of the survivors were followed up for between 1 and 5 years. During this time seven (19.4%) patients died, three (8.3%) became more independent, four (11.1%) less independent. Life table analysis of discharged patients showed no accelerated death rate in comparison with the normal population. The high mortality associated with burns in the elderly was confirmed. Half the survivors were at least temporarily less independent. Projected life expectancy for the elderly surviving a burn is comparable with his/her uninjured counterpart.     

Pharmacokinetic monitoring of nephrotoxic antibiotics in surgical intensive care patients

An assessment of the dosage regimens prescribed for potentially nephrotoxic antibiotics (amikacin, gentamicin, tobramycin, and vancomycin) was undertaken on surgical intensive care unit patients. In 166 patients, 224 series of blood antibiotic level determinations were obtained. Using individualized pharmacokinetic determinations, the regimens were revised as necessary to provide optimal blood levels. Because of variable volumes of distribution and elimination rates, dosing according to standard clinical guidelines produced significantly lower peaks than did pharmacokinetically determined regimens for gentamicin (p less than 0.005), tobramycin (p less than 0.0001), and vancomycin (p less than 0.05). Importantly, fewer patients achieved therapeutic levels with the original regimens than with the revised regimens for gentamicin (9% vs. 91%, p less than 0.0005), tobramycin (27% vs. 92%, p less than 0.0001), and vancomycin (30% vs. 69%, p less than 0.0001). Individualized pharmacokinetic analysis of potentially nephrotoxic antibiotics in critically ill patients is essential if therapeutic, non-toxic levels are to be maintained.     

Pulse contour cardiac output in surgical intensive care unit patients

Study Objective: To evaluate the ability of arterial waveform contour analysis to measure cardiac output (CO) continuously in postoperative critically ill patients.

Design: Thermodilution CO (TDCO) measurements were compared with simultaneous pulse contour CO (PCCO) measurements.

Setting: University hospital surgical intensive care unit.

Patients: 29 critically ill surgical patients with indwelling systemic arterial and pulmonary artery catheters.

Measurements and Main Results: TDCO measurements were compared with PCCO at 1- to 2-hour intervals. Mean TDCO was 5.75 ± 1.79 L/min, and mean PCCO was 5.76 ± 1.83 L/min. Analysis of the difference between TDCO and PCCO showed a bias of 0.01 ± 0.5 L/min. Comparison of the difference between pairs of sequential TDCO measurements and the initial TDCO and subsequent PCCO measurements resulted in a correlation coefficient of 0.64.

Conclusions: The PCCO method appears to be able to estimate changes in CO under the conditions tested, in which PCCO was recalibrated after each TDCO measurement. However, limitations of this method in the immediate postoperative period following aortic aneurysm surgery were identified.