Heart rate variability in critical illness and critical care

Although the rhythm of a healthy heart is clinically described as regular, the rate is variable. Studies of diverse populations have led to several generalizations about heart rate variability (HRV): (1) HRV is physiologic and normally declines with age, (2) acute changes in HRV are associated with several disease processes that require critical care, (3) measures of HRV can be used to describe the status of critically ill patients, and (4) measures of HRV can be used to predict events subsequent to at least one type of critical illness, myocardial infarction. This brief review considers the mechanisms underlying HRV, the measures that are used to describe HRV, and recent information regarding the use of HRV measures as predictive tools in critical care. The reviewers' opinion is that real-time analysis of HRV in critical illness may provide caregivers with additional information about patient status, effects of intervention, and prognosis.     

Frailty as a predictor of short- and long-term mortality in critically ill older medical patients

PurposeFrailty is a common condition among critically ill patients. Usually evaluated in a mixed population of medical, cardiac and surgical patients, we aimed to assess the impact of frailty on short- and long-term mortality exclusively in critically ill older medical patients.Materials and methodsWe included 285 patients aged≥70 years admitted to ICU (2009–2017). Comorbidities, severity scores, treatment intensity and complications were recorded. Pre-hospital frailty, measured by Clinical Frailty Scale (CFS), was defined as a score ≥ 5 according to this scale.ResultsPrevalence of frailty (CFS ≥ 5) of 18.6%. Frail patients were more likely to be female (64.2% vs. 35.6%, p < .001) or suffer from heart failure (17% vs. 6%,p = .021). Apache II score was higher in frail than in non-frail patients (27.4 ± 7.1 vs. 24.8 ± 8.6,p = .041). Age, comorbidities, treatment intensity, complications, and ICU and hospital length of stay were similar between frail and non-frail patients. Life-sustaining treatment limitation was more frequent in frail patients (47.2% vs. 20.7%,p < .001). Except for ICU mortality, frailty was an independent predictor of short- and long-term mortality after adjustment for sociodemographic, comorbidities, severity scores, treatment intensity and complications.ConclusionsFrailty (CFS ≥ 5) was independently associated with short- and long-term mortality in older patients admitted to ICU exclusively due to a medical reason.     

Development and evaluation of a simple, direct, solid-phase radioimmunoassay of serum cortisol from readily available reagents

A simple, rapid solid-phase radioimmunoassay for serum cortisol was developed using cortisol antibody distributed by the Scottish Antibody Production Unit and commercially available radioiodinated cortisol ligand. The assay involves a 1-h incubation at ambient temperature, using the antibody covalently linked by the easily performed carbonyldiimidazole method, to microcrystalline cellulose. A detailed comparison of the accepted 0.125 mol/l citrate, pH 4.0, and an alternative 0.1 mol/l phosphate/8-anilinonaphthalene sulphonic acid, pH 7.4, diluent demonstrated similar precision (within-assay 10% to 5%; between-assay 11% to 6% over the range 100-1000 nmol/l cortisol) and recovery (median recoveries: phosphate 98.6%, citrate 99.5%). Linear regression analysis of human serum cortisol concentrations in comparison with the 'Amerlex' cortisol RIA kit gave the following results: citrate = 1.029. 'Amerlex' - 3.5 nmol/l (n = 80, r = 0.967); phosphate = 1.017, 'Amerlex' + 26.2 nmol/l (n = 80, r = 0.961). Phosphate, pH 7.4 diluent was adopted as the diluent of choice, since it was economical of antibody and maintained good precision over a wider working range of cortisol concentration.     

Ward mortality after ICU discharge: a multicenter validation of the Sabadell score

Background  

Tools for predicting post-ICU patients’ outcomes are scarce. A single-center study showed that the Sabadell score classified patients into four groups with clear-cut differences in ward mortality.     

Use of a personal diary written on the ICU during critical illness

OBJECTIVE: To explore the use of a diary as an aid in debriefing patients and relatives following critical illness. DESIGN: Observation study. SETTING: Intensive care unit of a 500-bed hospital. PATIENTS AND PARTICIPANTS: Fifty-one critically ill patients and their relatives. METHOD: A daily account of the patient's progress was written in everyday language by nursing staff, photographs were added as necessary. The booklet was given to the patient or a relative at a follow-up appointment 2 weeks after discharge from the unit. A standard questionnaire was mailed 6 months later, responses were analyzed by an independent observer. MEASUREMENTS AND RESULTS: All diaries had been read by survivors (n = 41) or relatives (n = 10), 51% of the diaries had been read more than 10 times. Comments in the questionnaires were graded as very positive (39%), positive (28%) and neutral (33%). CONCLUSIONS: A detailed narrative of the patient's stay is a useful tool in the debriefing process following intensive care.     

Red cell distribution width as a novel predictor of mortality in ICU patients

Abstract

Background. The red cell distribution width (RDW) in ICU patients has never been investigated. Methods. A total of 602 consecutive patients were prospectively enrolled. We collected each patient's base-line characteristics including the Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, RDW, and C-reactive protein (CRP). The primary outcome for this analysis was ICU mortality, and secondary outcome was the total length of stay in hospital (TLSH). Potential predictors were analyzed for possible association with outcomes. Results. There was a significantly graded increase in APACHE-II score (tertile I = 10.7 ± 6.5 versus tertile II = 13.3 ± 6.2 versus tertile III = 15.8 ± 7.2; all P < 0.001) and ICU mortality rate (tertile I = 11.2% versus tertile II = 18.8% versus tertile III = 33.8%; all P < 0.001) across increasing of RDW tertile. As compared with APACHE-II score, combination of RDW and APACHE-II score increased the area under the curve (AUC) for predicting ICU mortality from 0.832 ± 0.020 to 0.885 ± 0.017 (P < 0.05). Multivariate analysis demonstrated that RDW, APACHE-II score, and CRP were independent predictors of ICU mortality (P < 0.05). RDW was also independently associated with TLSH in patients alive (P < 0.05). Conclusion. We found a graded independent relation between higher RDW and adverse outcomes in ICU patients. RDW has the potentially clinical utility to predict outcome in ICU patients.     

急性危重病患者血乳酸(LACT)与血气检测的临床应用

目的 探讨急性危重病患者血清乳酸(LACT)和血气的临床应用.方法 对65例急性危重病患者和25例正常对照组同步测定乳酸(LACT)与血气指标.结果 急性危重病患者组血气指标与正常对照组差异无显著性(P＞0.05);但危重病患者组乳酸浓度和血糖浓度较正常对照组明显升高(P＜0.01).结论 急性危重病患者由于缺氧、高代谢、低灌注等原因,在未出现明显酸中毒之前即可有高乳酸血症存在,因此对危重病患者进行乳酸和血气检测有非常重要的临床意义.     

Medically unexplained illness in short- and long-term disability applicants: Prevalence and cost of salary reimbursement

Purpose. Compared to patients with explained illness, patients with medically unexplained illness (MUI) may be at elevated risk of applying for disability. Accordingly, patients with MUI may account for a disproportionate number of disability claims and for a disproportionate percentage of salary reimbursement costs. The study was conducted to determine: (a) The prevalence of MUI among disability insurance claimants; (b) the cost of salary reimbursement; and (c) the impact of psychiatric comorbidity on length and cost of disability.

Method. An insurance database of 26,451 short-term disability (STD) recipients with long-term disability (LTD) coverage was analyzed to determine the prevalence and salary reimbursement costs of MUI. Applicants with medically explained and psychiatric illness were included for comparison.

Results. The prevalence of MUI among STD recipients was lower than clinical and community rates. Rates of application and receipt of LTD benefits for MUI were similar to explained illness. When LTD payments were projected to retirement age, costs associated with unexplained back pain and fibromyalgia were comparable to those of explained illness. The length of disability and salary reimbursement costs were greater when comorbid psychiatric illness was present.

Conclusions. Patients with MUI did not account for a disproportionate number of disability claims or amount of the money spent on salary reimbursement. Comorbid psychiatric illness increased the length and cost of disability.     

Heart rate recovery following maximal exercise testing as a predictor of cardiovascular disease and all-cause mortality in men with diabetes

OBJECTIVE: Heart rate recovery (HRR) is an independent prognostic indicator for cardiovascular disease (CVD) and all-cause mortality in healthy men. We examined the association of HRR to CVD-related and all-cause mortality in men with diabetes. RESEARCH DESIGN AND METHODS: In this cohort study we examined 2,333 men with documented diabetes (mean age 49.4 years) that had baseline 5-min HRR measurement following maximal exercise (heart rate(peak) - heart rate(5 min of recovery)) at The Cooper Clinic, Dallas, TX. We identified HRR quartiles as quartile 1 <55, quartile 2 55-66, quartile 3 67-75, and quartile 4 >75 bpm. Hazard ratios (HRs) for cardiovascular and all-cause death were adjusted for age, cardiorespiratory fitness, resting heart rate, fasting blood glucose, BMI, smoking habit, alcohol consumption, total cholesterol, triglyceride, and history of CVD at baseline. RESULTS: During a median of 14.9 years follow-up, there were 142 deaths that were considered CVD related and 287 total deaths. Compared with men in the highest quartile of HRR, adjusted HRs in the first, second, and third quartiles were 2.0 (95% CI 1.1-3.8), 1.5 (0.8-2.7), and 1.5 (0.9-2.8), respectively, for cardiovascular death (P for trend < 0.001). Similarly, for all-cause death, adjusted HRs in the first, second, and third quartiles were 2.0 (1.3-3.2), 1.5 (1.0-2.3), and 1.5 (1.1-2.3) (P for trend < 0.001). CONCLUSIONS: Among men with diabetes, a decreased HRR, even measured as long as 5 min after recovery, was independently predictive of cardiovascular and all-cause death.     

Short- and long-term impact of critical illness on relatives: literature review

Title. Short‐ and long‐term impact of critical illness on relatives: literature review. Aim. This paper is a report of a literature review undertaken to identify the short‐ and long‐term impact of critical illness on relatives. Background. Patients in intensive care can experience physical and psychological consequences, and their relatives may also experience such effects. Although it is recognized that relatives have specific needs, it is not clear whether these needs are always met and whether further support is required, particularly after intensive care. Data sources. The following databases were searched for the period 1950–2007: Medline, British Nursing Index and Archive, EMBASE, CINAHL, PsycINFO and EMB Reviews – Cochrane Central Register of Clinical Trials. Search methods. Search terms focused on adult relatives of critically ill adult patients during and after intensive care. Recurrent topics were categorized to structure the review, i.e. ‘relatives needs’, ‘meeting relatives’ needs’, ‘interventions’, ‘satisfaction’, ‘psychological outcomes’ and ‘coping’. Results. Studies have mainly identified relatives’ immediate needs using the Critical Care Family Needs Inventory. There are few studies of interventions to meet relatives’ needs and the short‐ and long‐term effects of critical illness on relatives. Conclusion. Despite widespread use of the Critical Care Family Needs Inventory, factors such as local or cultural differences may influence relatives’ needs. Relatives may also have unidentified needs, and these needs should be explored. Limited research has been carried out into interventions to meet relatives’ needs and the effects of critical illness on their well‐being, yet some relatives may experience negative psychological consequences far beyond the acute phase of the illness.     

Corticosteroids influence the mortality and morbidity of acute critical illness

Introduction  

Use of corticosteroids for adrenal supplementation and attenuation of the inflammatory and immune response is widespread in acute critical illness. The study hypothesis was that exposure to corticosteroids influences the mortality and morbidity in acute critical illness.