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Background: Because mortality and amputation rates are declining for necrotizing soft tissue infections (NSTIs), this study aimed to assesses the self-reported one-year quality of life (QoL) of severely ill patients with NSTI who survived beyond the intensive care unit (ICU). Patients and Methods: A retrospective cohort study of patients with NSTI admitted to the ICU between 2010 and 2019 was conducted. A year after ICU discharge, QoL was assessed using the three-level EuroQol five-dimensions (EQ-5D-3L) questionnaire, Impact of Event Scale-Revised (IES-R) questionnaires, and pain scales. Furthermore, willingness to undergo ICU admission again if needed was reviewed. Results: Twenty-nine (of 38) patients with NSTI survived their hospitalization (76%). During the one-year follow-up, three patients died (8%; one-year survival 68%). Nineteen patients filled out the questionnaires (73%). The median EQ-5D-3L index score was 0.775 (interquartile range [IQR], 0.687-0.843). The domains reported most to cause impairment were "usual activity" and "pain/discomfort." Patients had a median pain score of five (of 10; IQR, 1-6) and two patients (15%; of 13) scored "clinical concern for PTSD.". Eighty-five percent of the patients would undergo the ICU treatment again if needed. Conclusions: The one-year QoL of ICU-admitted patients with NSTI varies widely, however, the overall QoL and one-year survival was similar to other ICU patients who underwent acute surgery and the QoL was slightly lower than the general ICU population. Most patients experience problems with daily activity and pain, but this does not mean that patients with NSTI automatically had poor self-reported quality of life or unwillingness to undergo ICU treatment again if needed.
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Calidad de Vida , Infecciones de los Tejidos Blandos , Humanos , Infecciones de los Tejidos Blandos/terapia , Estudios Retrospectivos , Unidades de Cuidados Intensivos , Encuestas y Cuestionarios , DolorRESUMEN
To compare mental, cognitive and physical outcomes between COVID-19 and non-COVID-19 patients, 3-6 months after Intensive Care Unit (ICU) treatment during the COVID-19 pandemic and to compare mental outcomes between relatives of these patients. This retrospective cohort study included 209 ICU survivors (141 COVID-19 patients and 68 non-COVID-19 patients) and 168 of their relatives (maximum one per patient) during the COVID-19 pandemic. Primary outcomes were self-reported occurrence of mental, cognitive and/or physical symptoms 3-6 months after ICU discharge. The occurrence of mental symptoms did not differ between former COVID-19 patients (34.7% [43/124]) and non-COVID-19 patients (43.5% [27/62]) (p = 0.309), neither between relatives of COVID-19 patients (37.6% [38/101]) and relatives of non-COVID-19 patients (39.6% [21/53]) (p = 0.946). Depression scores on the Hospital Anxiety and Depression Scale were lower in former COVID-19 patients, compared to non-COVID-19 patients (p = 0.025). We found no differences between COVID-19 and non-COVID-19 patients in cognitive and physical outcomes. Mental, cognitive and physical outcomes in COVID-19 ICU survivors were similar to non-COVID-19 ICU survivors. Mental symptoms in relatives of COVID-19 ICU survivors did not differ from relatives of non-COVID-19 ICU survivors, within the same time frame.
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COVID-19 , Humanos , COVID-19/epidemiología , Pandemias , Estudios Retrospectivos , Unidades de Cuidados Intensivos , CogniciónRESUMEN
Background: The aim of this study was to identify the cause of death in patients with necrotizing soft tissue infections (NSTIs) stratified by patient's pre-existing comorbidities (American Society of Anesthesiologists [ASA] classification 3/4 vs. ASA 1/2). Differences in clinical presentation, mortality rate, and factors associated with mortality between those two comorbidity groups were investigated. Patients and Methods: A retrospective multicenter study of patients with NSTIs between 2010 and 2020 was conducted. The primary outcome was the cause of death within the first 30 days. Furthermore, factors associated with mortality were identified. All analysis were stratified by severity of comorbidities (ASA 1/2 or ASA 3/4). Results: Of the 187 patients, 39 patients (21%) died within 30 days. American Society of Anesthesiologists 1/2 patients (overall mortality rate, 11%) died more often as direct result of the infection compared with ASA 3/4 patients (overall mortality rate, 33%) (ASA 1/2 group: 92% vs. ASA 3/4 group: 48%; p = 0.013). American Society of Anesthesiologists 3/4 patients died more often due to withdrawal of life-sustaining therapies based on assumed poor outcome after severe critical illness (ASA 1/2 group: 52% vs. ASA 3/4 group: 8%; p = 0.013). Conclusions: Mortality rates of patients with NSTIs varied from 11% in previously healthy patients to 33% in patients with multiple or severe comorbidities. The predominant cause of mortality was overwhelming infection and associated sepsis in healthy patients whereas in patients with multiple or severe pre-existing medical disease, death most often occurred after treatment limitations based on patient's wishes and prognosis.
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Infecciones de los Tejidos Blandos , Causas de Muerte , Comorbilidad , Humanos , Pronóstico , Estudios Retrospectivos , Infecciones de los Tejidos Blandos/epidemiologíaRESUMEN
BACKGROUND: Multiple factors contribute to mortality after ICU, but it is unclear how the predictive value of these factors changes during ICU admission. We aimed to compare the changing performance over time of the acute illness component, antecedent patient characteristics, and ICU length of stay (LOS) in predicting 1-year mortality. METHODS: In this retrospective observational cohort study, the discriminative value of four generalized mixed-effects models was compared for 1-year and hospital mortality. Among patients with increasing ICU LOS, the models included (a) acute illness factors and antecedent patient characteristics combined, (b) acute component only, (c) antecedent patient characteristics only, and (d) ICU LOS. For each analysis, discrimination was measured by area under the receiver operating characteristics curve (AUC), calculated using the bootstrap method. Statistical significance between the models was assessed using the DeLong method (p value < 0.05). RESULTS: In 400,248 ICU patients observed, hospital mortality was 11.8% and 1-year mortality 21.8%. At ICU admission, the combined model predicted 1-year mortality with an AUC of 0.84 (95% CI 0.84-0.84). When analyzed separately, the acute component progressively lost predictive power. From an ICU admission of at least 3 days, antecedent characteristics significantly exceeded the predictive value of the acute component for 1-year mortality, AUC 0.68 (95% CI 0.68-0.69) versus 0.67 (95% CI 0.67-0.68) (p value < 0.001). For hospital mortality, antecedent characteristics outperformed the acute component from a LOS of at least 7 days, comprising 7.8% of patients and accounting for 52.4% of all bed days. ICU LOS predicted 1-year mortality with an AUC of 0.52 (95% CI 0.51-0.53) and hospital mortality with an AUC of 0.54 (95% CI 0.53-0.55) for patients with a LOS of at least 7 days. CONCLUSIONS: Comparing the predictive value of factors influencing 1-year mortality for patients with increasing ICU LOS, antecedent patient characteristics are more predictive than the acute component for patients with an ICU LOS of at least 3 days. For hospital mortality, antecedent patient characteristics outperform the acute component for patients with an ICU LOS of at least 7 days. After the first week of ICU admission, LOS itself is not predictive of hospital nor 1-year mortality.
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Enfermedad Crítica/mortalidad , Características Humanas , Medición de Riesgo/normas , Anciano , Área Bajo la Curva , Estudios de Cohortes , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Unidades de Cuidados Intensivos/organización & administración , Unidades de Cuidados Intensivos/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Países Bajos , Curva ROC , Estudios Retrospectivos , Medición de Riesgo/métodos , Medición de Riesgo/estadística & datos numéricosRESUMEN
OBJECTIVES: To develop a consensus framework that can guide the process of decision-making on continuing or limiting life-sustaining treatments in ICU patients, using evidence-based items, supported by caregivers, patients, and surrogate decision makers from multiple countries. DESIGN: A three-round web-based international Delphi consensus study with a priori consensus definition was conducted with experts from 13 countries. Participants reviewed items of the decision-making process on a seven-point Likert scale or with open-ended questions. Questions concerned terminology, content, and timing of decision-making steps. The summarized results (including mean scores) and expert suggestions were presented in the subsequent round for review. SETTING: Web-based surveys of international participants representing ICU physicians, nurses, former ICU patients, and surrogate decision makers. PATIENTS: Not applicable. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: In three rounds, respectively, 28, 28, and 27 (of 33 invited) physicians together with 12, 10, and seven (of 19 invited) nurses participated. Patients and surrogates were involved in round one and 12 of 27 responded. Caregivers were mostly working in university affiliated hospitals in Northern Europe. During the Delphi process, most items were modified in order to reach consensus. Seven items lacked consensus after three rounds. The final consensus framework comprises the content and timing of four elements; three elements focused on caregiver-surrogate communication (admission meeting, follow-up meeting, goals-of-care meeting); and one element (weekly time-out meeting) focused on assessing preferences, prognosis, and proportionality of ICU treatment among professionals. CONCLUSIONS: Physicians, nurses, patients, and surrogates generated a consensus-based framework to guide the process of decision-making on continuing or limiting life-sustaining treatments in the ICU. Early, frequent, and scheduled family meetings combined with a repeated multidisciplinary time-out meeting may support decisions in relation to patient preferences, prognosis, and proportionality.
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Toma de Decisiones Clínicas/métodos , Unidades de Cuidados Intensivos/organización & administración , Cuidados para Prolongación de la Vida/métodos , Privación de Tratamiento/normas , Actitud del Personal de Salud , Cuidadores/psicología , Toma de Decisiones Clínicas/ética , Comunicación , Técnicas de Apoyo para la Decisión , Técnica Delphi , Práctica Clínica Basada en la Evidencia , Humanos , Unidades de Cuidados Intensivos/ética , Unidades de Cuidados Intensivos/normas , Tutores Legales/psicología , Cuidados para Prolongación de la Vida/ética , Cuidados para Prolongación de la Vida/normas , Pacientes/psicología , Pronóstico , Privación de Tratamiento/éticaRESUMEN
PURPOSE: Poor neuropsychiatric outcomes are common in survivors of critical illness but it is unclear what patient groups to target for interventions to improve mental health. We compared anxiety, depression, and post-traumatic stress disorder (PTSD) symptoms and health-related quality of life (HrQoL) across different subgroups of Intensive Care Unit (ICU) survivors. MATERIALS AND METHODS: A single-center cohort study was conducted in a mixed-ICU in the Netherlands among survivors of an ICU admission ≥48â¯h (nâ¯=â¯1730). Survivors received a survey one year after discharge, containing the Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale (IES/IES-R), and EQ-5D (response rate of 67%). Neuropsychiatric symptoms and quality of life were evaluated in a priori defined subgroups, by chi-square tests and Mann-Whitney U tests. RESULTS: Symptoms of anxiety (HADS anxiety ≥8), depression (HADS depression ≥8), and PTSD (IES ≥35; IES-Râ¯≥â¯1.6) were reported by 34%, 33%, and 19% of ICU survivors, with a median HrQoL utility score of 0.81 (IQR:0.65-1.00). These figures were similar for survivors of ARDS, sepsis, severe multiple organ failure (SOFA>11), or ICU stay ≥7â¯days. CONCLUSIONS: This underlines the importance of prevention and treatment for neuropsychiatric symptoms in ICU survivors in general, not only in specific patient groups.
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Ansiedad/psicología , Enfermedad Crítica/psicología , Depresión/psicología , Calidad de Vida , Trastornos por Estrés Postraumático/psicología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Hospitalización , Humanos , Unidades de Cuidados Intensivos , Masculino , Salud Mental , Persona de Mediana Edad , Países Bajos , Alta del Paciente , Estudios Prospectivos , Psicometría , Encuestas y Cuestionarios , Sobrevivientes/psicología , Adulto JovenRESUMEN
More and more elderly patients are being admitted to the hospital. These elderly patients represent a significant proportion of intensive care unit (ICU) admissions. Older ICU patients have a high risk of death during their ICU admission and, if they do survive, a high risk of physical and cognitive decline. In addition, their remaining life expectancy is often limited. In short, elderly patients have less to gain from ICU treatment than young patients. It is therefore important to carefully consider the proportionality of ICU treatment. In this clinical lesson, we discuss aspects of the elderly ICU patient that should be taken into account when considering ICU treatment, in acute situations as well as in outpatient or GP settings.
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Mortalidad Hospitalaria , Unidades de Cuidados Intensivos/estadística & datos numéricos , Admisión del Paciente/estadística & datos numéricos , Anciano de 80 o más Años , Cuidados Críticos , Femenino , Hospitalización , Humanos , Esperanza de Vida , Estudios RetrospectivosRESUMEN
PURPOSE: Survivors of critical illness often suffer from reduced health-related quality of life (HRQoL) due to long-term physical, cognitive, and mental health problems, also known as post-intensive care syndrome (PICS). Some intensive care unit (ICU) survivors even consider their state of health unacceptable. The aim of this study was to investigate the determinants of self-reported unacceptable outcome of ICU treatment. METHODS: Patients who were admitted to the ICU for at least 48 h and survived the first year after discharge completed validated questionnaires on overall HRQoL and the components of PICS and stated whether they considered their current state of health an acceptable outcome of ICU treatment. The effects of overall HRQoL and components of PICS on unacceptable outcome were studied using multiple logistic regression analysis. RESULTS: Of 1453 patients, 67 (5%) reported their health state an unacceptable outcome of ICU treatment. These patients had a lower score on overall HRQoL (EQ-5D-index value of 0.57 vs. 0.81; p < 0.001), but we could not determine a cutoff value of the EQ-5D-index value that reliably identified unacceptable outcome. In the multivariate analysis, only the hospital anxiety and depression scale was significantly associated with an unacceptable outcome (OR 2.06, 99% CI 1.18-3.61). CONCLUSIONS: Although there is a strong association between low overall HRQoL and self-reported unacceptable outcome of ICU treatment, patients with low overall HRQoL may still consider their outcome acceptable. The mental component of PICS, but not the physical and cognitive component, is strongly associated with self-reported unacceptable outcome.
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Unidades de Cuidados Intensivos/estadística & datos numéricos , Evaluación del Resultado de la Atención al Paciente , Calidad de Vida/psicología , Autoinforme , Factores de Tiempo , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Unidades de Cuidados Intensivos/organización & administración , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Alta del Paciente/normas , Alta del Paciente/estadística & datos numéricos , Psicometría/instrumentación , Psicometría/métodos , Encuestas y Cuestionarios , Sobrevivientes/psicologíaRESUMEN
PURPOSE: Many patients in the Intensive Care Unit (ICU) die after a decision to withhold or withdraw treatment. To ensure that for each patient the appropriate decision is taken, a careful decision-making process is required. This review identifies strategies that can be used to optimize the decision-making process for continuing versus limiting life sustaining treatment of ICU patients. METHODS: We conducted a systematic review of the literature by searching PUBMED and EMBASE. RESULTS: Thirty-two studies were included, with five categories of decision-making strategies (1) integrated communication, (2) consultative communication, (3) ethics consultation, (4) palliative care consultation and (5) decision aids. Many different outcome measures were used and none of them covered all aspects of decisions on continuing versus limiting life sustaining treatment. Integrated communication strategies had a positive effect on multiple outcome measures. Frequent, predefined family-meetings as well as triggered and integrated ethical or palliative consultation were able to reduce length of stay of patients who eventually died, without increasing overall mortality. CONCLUSIONS: The decision-making process in the ICU can be enhanced by frequent family-meetings with predefined topics. Ethical and palliative support is useful in specific situations. These interventions can reduce non-beneficial ICU treatment days.
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Enfermedad Crítica/terapia , Unidades de Cuidados Intensivos/organización & administración , Cuidados para Prolongación de la Vida/organización & administración , Comunicación , Toma de Decisiones , Técnicas de Apoyo para la Decisión , Humanos , Unidades de Cuidados Intensivos/ética , Cuidados para Prolongación de la Vida/éticaRESUMEN
Patients admitted to an intensive care unit (ICU) comprise of a heterogeneous population with substantial differences in admission diagnosis, length of stay and co-morbidity. Therefore, very often the prognosis for each patient differs. In the Netherlands, over 20% of the more than 80,000 patients treated in ICU annually will die within a year of admission. Some of those who survive and are discharged from ICU experience persistent physical, mental and cognitive health problems post-discharge; this is called post-intensive care syndrome (PICS). One year following discharge, circa 50% of patients continue to report physical symptoms, including muscle weakness and walking difficulties. Approximately one in five patients discharged from ICU will develop symptoms akin to post-traumatic stress disorder, and one third will experience depressive symptoms for some time. It remains unclear to what extent the actual ICU admission may potentially contribute to the decline in performance status and quality of life.
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Cuidados Críticos/psicología , Hospitalización/estadística & datos numéricos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Calidad de Vida , Depresión/epidemiología , Humanos , Debilidad Muscular/epidemiología , Países Bajos , Alta del Paciente/estadística & datos numéricos , PronósticoRESUMEN
OBJECTIVES: To improve patient safety, potential critical events should be analyzed for the existence of preventive barriers. The aim of this study was to prospectively identify existing and missing barriers using the Bow-Tie model. We expected that the analysis of these barriers would lead to feasible recommendations to improve safety in daily patient care. METHODS: Multidisciplinary teams of doctors and nurses on a 28 bed ICU conducted the study. The Bow-Tie analysis was performed on intrahospital transportation, unplanned extubation, and communication, which led to 9 critical events. For each event, potential threats and consequences were defined and placed in a Bow-Tie diagram. Then, barriers were determined, ways to prevent the threat or limit the consequences. The barriers were defined as existing or missing and analyzed for feasibility. RESULTS: Intrahospital transportation: this hazard led to 7 critical events, the Bow-Tie analysis to 52 missing but implementable barriers and 8 practical recommendations. For example, a pretransportation checklist.Unplanned extubation: this Bow-Tie analysis revealed 15 implementable missing barriers (of a total of 32) and led to 22 recommendations. One of them was optimizing treatment of delirium.Communication: this analysis showed 21 barriers, of which, 12 were missing but feasible to implement. These barriers led to 7 recommendations such as the need to cosign after the handover of a patient. CONCLUSIONS: Prospective risk analysis using the Bow-Tie model proved usable to identify existing and missing barriers for potential critical events. Many missing barriers seemed feasible to implement and led to practical recommendations and improvements in patient safety.
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Unidades de Cuidados Intensivos , Seguridad del Paciente/normas , Medición de Riesgo/métodos , Humanos , Unidades de Cuidados Intensivos/normas , Unidades de Cuidados Intensivos/estadística & datos numéricos , Países Bajos , Estudios Prospectivos , Centros de Atención Terciaria , Transporte de PacientesRESUMEN
BACKGROUND: A non-traumatic rupture of the spleen is a rare, serious condition with a high mortality rate. This sort of rupture can occur in a healthy patient or in patients with an underlying disease such as an infection or a haematological disorder. CASE DESCRIPTION: Here we describe a 52-year-old man who had Legionella pneumonia and suffered a spontaneous rupture of the spleen. He had to undergo a splenectomy following an unsuccessful embolisation of the lienal artery. He recovered. In the second patient, a 73-year-old man with monoclonal gammopathy, rupture of the spleen was caused by amyloidosis of the spleen. CONCLUSION: Rupture of the spleen can cause life threatening haemorrhage, so early recognition is important.