Early rehabilitation during extracorporeal membrane oxygenation has minimal impact on physiological parameters: A pilot randomised controlled trial.

BACKGROUND: Patients on extracorporeal membrane oxygenation (ECMO) often require prolonged periods of bed rest owing to their severity of illness along with the care required to maintain the position and integrity of the ECMO cannula. Many patients on ECMO receive passive exercises, and rehabilitation is often delayed owing to medical instability, with a high proportion of patients demonstrating severe muscle weakness. The physiological effects of an intensive rehabilitation program started early after ECMO commencement remain unknown. OBJECTIVES: The primary objective of this study was to describe the respiratory and haemodynamic effects of early intensive rehabilitation compared with standard care physiotherapy over a 7-d period in patients requiring ECMO. METHODS: This was a physiological substudy of a multicentre randomised controlled trial conducted in one tertiary referral hospital. Consecutive adult patients undergoing ECMO were recruited. Respiratory and haemodynamic parameters, along with ECMO settings, were recorded 30 min before and after each session and continuously during the session. In addition, the minimum and maximum values for these parameters were recorded outside of the rehabilitation or standard care sessions for each 24-h period over the 7 d. The number of minutes of exercise per session was recorded. RESULTS: Fifteen patients (mean age = 51.5 ± standard deviation of 14.3 y, 80% men) received ECMO. There was no difference between the groups for any of the respiratory, haemodynamic, or ECMO parameters. The minimum and maximum values for each parameter were recorded outside of the rehabilitation or standard care sessions. The intensive rehabilitation group (n = 7) spent more time exercising per session than the standard care group (n = 8) (mean = 28.7 versus 4.2 min, p < 0.0001). Three patients (43%) in the intensive rehabilitation group versus none in the standard care group mobilised out of bed during ECMO. CONCLUSIONS: In summary, early intensive rehabilitation of patients on ECMO had minimal effect on physiological parameters.

Potential role for extracorporeal membrane oxygenation cardiopulmonary resuscitation (E-CPR) during in-hospital cardiac arrest in Australia: A nested cohort study.

Objective: This study aims to evaluate the characteristics and outcomes of patients who fulfilled extracorporeal membrane oxygenation cardiopulmonary resuscitation (E-CPR) selection criteria during in-hospital cardiac arrest (IHCA). Design: This is a nested cohort study. Setting: Code blue data were collected across seven hospitals in Australia between July 2017 and August 2018. Participants: Participants who fulfilled E-CPR selection criteria during IHCA were included. Main outcome measures: Return of spontaneous circulation and survival and functional outcome at hospital discharge. Functional outcome was measured using the modified Rankin scale, with scores dichotomised into good and poor functional outcome. Results: Twenty-three (23/144; 16%) patients fulfilled E-CPR selection criteria during IHCA, and 11/23 (47.8%) had a poor outcome. Patients with a poor outcome were more likely to have a non-shockable rhythm (81.8% vs. 16.7%; p = 0.002), and a longer duration of CPR (median 12.5 [5.5, 39.5] vs. 1.5 [0.3, 2.5] minutes; p < 0.001) compared to those with a good outcome. The majority of patients (18/19 [94.7%]) achieved sustained return of spontaneous circulation within 15 minutes of CPR. All five patients who had CPR >15 minutes had a poor outcome. Conclusion: Approximately one in six IHCA patients fulfilled E-CPR selection criteria during IHCA, half of whom had a poor outcome. Non-shockable rhythm and longer duration of CPR were associated with poor outcome. Patients who had CPR for >15 minutes and a poor outcome may have benefited from E-CPR. The feasibility, effectiveness and risks of commencing E-CPR earlier in IHCA and among those with non-shockable rhythms requires further investigation.

Predictors of death and new disability after critical illness: a multicentre prospective cohort study.

PURPOSE: This study aimed to determine the prevalence and predictors of death or new disability following critical illness. METHODS: Prospective, multicentre cohort study conducted in six metropolitan intensive care units (ICU). Participants were adults admitted to the ICU who received more than 24 h of mechanical ventilation. The primary outcome was death or new disability at 6 months, with new disability defined by a 10% increase in the WHODAS 2.0. RESULTS: Of 628 patients with the primary outcome available (median age of 62 [49-71] years, 379 [61.0%] had a medical admission and 370 (58.9%) died or developed new disability by 6 months. Independent predictors of death or new disability included age [OR 1.02 (1.01-1.03), P = 0.001], higher severity of illness (APACHE III) [OR 1.02 (1.01-1.03), P < 0.001] and admission diagnosis. Compared to patients with a surgical admission diagnosis, patients with a cardiac arrest [OR (95% CI) 4.06 (1.89-8.68), P < 0.001], sepsis [OR (95% CI) 2.43 (1.32-4.47), P = 0.004], or trauma [OR (95% CI) 6.24 (3.07-12.71), P < 0.001] diagnosis had higher odds of death or new disability, while patients with a lung transplant [OR (95% CI) 0.21 (0.07-0.58), P = 0.003] diagnosis had lower odds. A model including these three variables had good calibration (Brier score 0.20) and acceptable discriminative power with an area under the receiver operating characteristic curve of 0.76 (95% CI 0.72-0.80). CONCLUSION: Less than half of all patients mechanically ventilated for more than 24 h were alive and free of new disability at 6 months after admission to ICU. A model including age, illness severity and admission diagnosis has acceptable discriminative ability to predict death or new disability at 6 months.

Survival and functional outcome at hospital discharge following in-hospital cardiac arrest (IHCA): A prospective multicentre observational study.

AIM: To evaluate the functional outcome of patients after in-hospital cardiac arrest (IHCA) and to identify associations with good functional outcome at hospital discharge. METHOD: Emergency calls were prospectively screened and data collected for IHCAs in seven Australian hospitals. Patients were included if aged > 18 years, admitted as an acute care hospital in-patient and experienced IHCA; defined by a period of unresponsiveness with no observed respiratory effort and commencement of external cardiac compressions. Data collected included patient demographics, clinical and cardiac arrest characteristics, survival and functional outcome at hospital discharge using the modified Rankin Scale (mRS) and Katz Index of Independence in ADLs (Katz-ADL). RESULTS: 152 patients suffered 159 IHCAs (male 66.4%; mean age 70.2 (± 13.9) years). Sixty patients (39.5%) survived, of whom 43 (71.7%) had a good functional outcome (mRS ≤ 3) and 38 (63.3%) were independent with activities of daily living (ADLs) at hospital discharge (Katz-ADL = 6). Younger age (OR 0.95; 95% CI 0.91-0.98; p = 0.003), shorter duration of CPR (OR 0.84; 95% CI 0.77-0.91; p < 0.0001) and shorter duration of hospital admission prior to IHCA (OR 0.96; 95% CI 0.93-0.998; p = 0.04) were independently associated with a good functional outcome at hospital discharge. CONCLUSION: The majority of survivors had a good functional outcome and were independent with their ADLs at hospital discharge. Factors associated with good functional outcome at hospital discharge were identified.

Adaptation and validation of the ICU Mobility Scale in Spain. / Adaptación y validación de la ICU Mobility Scale en España.

OBJECTIVE: To adapt the ICU Mobility Scale (IMS) to the area of intensive care units (ICU) in Spain and to evaluate the metric properties of the Spanish version of the IMS (IMS-Es). METHOD: Descriptive metric study developed in two phases. Phase 1, adaptation to Spanish of the IMS by a team of nurses and physiotherapists (translation, pilot, backtranslation and agreement). Phase 2, analysis of metric properties (convergent, divergent and predictive validity, interobserver reliability, sensitivity and minimum important difference) of the IMS-Es. Patient characteristics (Barthel, Charlson, BMI, sex), sedation/agitation level (RASS), ICU and hospital stays, survival, quality of life (SF-12), muscle weakness (MRC-SS) and mobility (IMS-Es) were recorded in the patients of the MOviPre national multicentre study. RESULTS: After obtaining the IMS-Es, it was implemented in 645 patients from 80 Spanish ICUs between April and June 2017. Convergent validity: moderate correlation between IMS-Es and MRC-SS (r=.389; P<.001) and significant comparison between groups with and without ICU-acquired weakness (P<.001). Divergent validity: no correlation between IMS-Es and BMI [r (95%CI): -.112 (-.232 to .011)], weight [r (95%CI): -.098 (-.219 to .026)], Charlson [r (95%CI): -.122 (-.242 to .001)] and Barthel [r(95%CI): -.037 (-.160 to .087)] and no differences between sexes (P=.587) or BMI categories (P=.412). Predictive validity: moderate and significant correlations with post-ICU hospital stay [r (95%CI): -.442 (-.502 to -.377)] and physical component of SF-12 (PCS) [r (95%CI): .318 (.063 to .534)]; patients without active mobilisation in ICU increased risk of hospital mortality [OR (95%CI): 3.769 (1.428 to 9.947)]. Interobserver reliability: very good concordance between nurses [CCI (95%CI): .987 (.983 to .990)] and nurse-physiotherapist [CCI (95%CI): .963 (.948 to .974)]. Sensitivity to change: small effect on discharge from ICU (d=.273) and moderate effect at 3months after hospital discharge (d=.709). Minimal important difference: 2-point difference cut-off point, 91.1% sensitivity and 100.0% specificity. CONCLUSIONS: The IMS-Es is useful, valid and reliable for implementation by ICU nurses and physiotherapists in assessing the mobility of critical patients.

The rapid and accurate categorisation of critically ill patients (RACE) to identify outcomes of interest for longitudinal studies: a feasibility study.

The capacity to measure the impact of an intervention on long-term functional outcomes might be improved if research methodology reflected our clinical approach, which is to individualise goals of care to what is achievable for each patient. The objective of this multicentre inception cohort study was to evaluate the feasibility of rapidly and accurately categorising patients, who were eligible for simulated enrolment into a clinical trial, into unique categories based on premorbid function. Once a patient met eligibility criteria a rapid 'baseline assessment' was conducted to categorise patients into one of eight specified groups. A subsequent 'gold standard' assessment was made by an independent blinded assessor once patients had recovered sufficiently to allow such an assessment to occur. Accuracy was predefined as agreement in >80% of assessments. One hundred and twenty-two patients received a baseline assessment and 104 (85%) were categorised to a unique category. One hundred and six patients survived to have a gold standard assessment performed, with 100 (94%) assigned to a unique category. Ninety-two patients had both a baseline and gold standard assessment, and these agreed in 65 (71%) patients. It was not feasible to rapidly and accurately categorise patients according to premorbid function.

Comparison of forehead Max-Fast pulse oximetry sensor with finger sensor at high positive end-expiratory pressure in adult patients with acute respiratory distress syndrome.

In the critical care setting it may be difficult to determine an accurate reading of oxygen saturation from digital sensors as a result of poor peripheral perfusion. Limited evidence suggests that forehead sensors may be more accurate in these patients. We prospectively compared the accuracy of a forehead reflectance sensor (Max-Fast) with a conventional digital sensor in patients with acute respiratory distress syndrome during a high positive end-expiratory pressure (PEEP) recruitment manoeuvre (stepwise recruitment manoeuvre). Sixteen patients with early acute respiratory distress syndrome were enrolled to evaluate the blood oxygen saturation during a stepwise recruitment manoeuvre. PEEP was increased from baseline (range 10 to 18) to 40 cmH2O, then decreased to an optimal level determined by individual titration. Forehead and digital oxygen saturation and arterial blood gases were measured simultaneously before, during and after the stepwise recruitment manoeuvre at five time points. Seventy-three samples were included for analysis from 16 patients. The SaO2 values ranged from 73 to 99.6%. The forehead sensor provided measurements that deviated more from arterial measures than the finger sensor (mean absolute deviations 3.4%, 1.1% respectively, P=0.02). The greater variability in forehead measures taken at maximum PEEP was reflected in the unusually large precision estimates of 4.24% associated with these measures. No absolute differences from arterial measures taken at any other time points were significantly different. The finger sensor is as accurate as the forehead sensor in detecting changes in arterial oxygen saturation in adults with acute respiratory distress syndrome and it may be better at levels of high PEEP such as during recruitment manoeuvres.

Object-oriented analysis and design: a methodology for modeling the computer-based patient record.

The article highlights the importance of an object-oriented analysis and design (OOAD) methodology for the computer-based patient record (CPR) in the military environment. Many OOAD methodologies do not adequately scale up, allow for efficient reuse of their products, or accommodate legacy systems. A methodology that addresses these issues is formulated and used to demonstrate its applicability in a large-scale health care service system. During a period of 6 months, a team of object modelers and domain experts formulated an OOAD methodology tailored to the Department of Defense Military Health System and used it to produce components of an object model for simple order processing. This methodology and the lessons learned during its implementation are described. This approach is necessary to achieve broad interoperability among heterogeneous automated information systems.