ICU survivors show no decline in health-related quality of life after 5 years.

PURPOSE: Severe critical illness requiring treatment in the intensive care unit (ICU) may have a serious impact on patients and their families. However, optimal follow-up periods are not defined and data on health-related quality of life (HRQOL) before ICU admission as well as those beyond 2 years follow-up are limited. The aim of our study was to assess the impact of ICU stay up to 5 years after ICU discharge. METHODS: We performed a long-term prospective cohort study in patients admitted for longer than 48 h in a medical-surgical ICU. The Short-Form 36 was used to evaluate HRQOL before admission (by proxy within 48 h after admission of the patient), at ICU discharge, and at 1, 2, and 5 years following ICU discharge (all by patients). Changes in HRQOL were assessed using linear mixed modeling. RESULTS: We included a total of 749 patients (from 2000 to 2007). At 5 years after ICU discharge 234 patients could be evaluated. After correction for natural decline in HRQOL, the mean scores of four dimensions-physical functioning (p < 0.001), role-physical (p < 0.001), general health (p < 0.001), and social functioning (p = 0.003)-were still significantly lower 5 years after ICU discharge compared with their pre-admission levels, although effect sizes were small (<0.5). CONCLUSIONS: After correction for natural decline, the effect sizes of decreases in HRQOL were small, suggesting that patients regain their age-specific HRQOL 5 years after their ICU stay.

Cumulative lactate and hospital mortality in ICU patients.

BACKGROUND: Both hyperlactatemia and persistence of hyperlactatemia have been associated with bad outcome. We compared lactate and lactate-derived variables in outcome prediction. METHODS: Retrospective observational study. Case records from 2,251 consecutive intensive care unit (ICU) patients admitted between 2001 and 2007 were analyzed. Baseline characteristics, all lactate measurements, and in-hospital mortality were recorded. The time integral of arterial blood lactate levels above the upper normal threshold of 2.2 mmol/L (lactate-time-integral), maximum lactate (max-lactate), and time-to-first-normalization were calculated. Survivors and nonsurvivors were compared and receiver operating characteristic (ROC) analysis were applied. RESULTS: A total of 20,755 lactate measurements were analyzed. Data are srpehown as median [interquartile range]. In nonsurvivors (n = 405) lactate-time-integral (192 [0-1881] min·mmol/L) and time-to-first normalization (44.0 [0-427] min) were higher than in hospital survivors (n = 1846; 0 [0-134] min·mmol/L and 0 [0-75] min, respectively; all p < 0.001). Normalization of lactate <6 hours after ICU admission revealed better survival compared with normalization of lactate >6 hours (mortality 16.6% vs. 24.4%; p < 0.001). AUC of ROC curves to predict in-hospital mortality was the largest for max-lactate, whereas it was not different among all other lactate derived variables (all p > 0.05). The area under the ROC curves for admission lactate and lactate-time-integral was not different (p = 0.36). CONCLUSIONS: Hyperlactatemia is associated with in-hospital mortality in a heterogeneous ICU population. In our patients, lactate peak values predicted in-hospital mortality equally well as lactate-time-integral of arterial blood lactate levels above the upper normal threshold.

[The life of ICU-survivors]. / Het leven van een Intensive-Care-overlever.

Many ICU survivors experience physical, cognitive and mental complications of critical care. This phenomenon has recently been defined as post-intensive care syndrome (PICS). We present 2 patients who survived treatment in an ICU. One of these patients, a 71-year-old male, had pneumosepsis and multiple organ failure. He was treated for 10 days in the ICU. He made a full recovery after 3 months of rehabilitation. The second patient, a 61-year-old male, developed multiple organ failure as complication of acute necrotizing pancreatitis. He was treated for 55 days in the ICU. He ultimately survived, but later developed a post-intensive care syndrome that had a long-lasting impact on his quality of life. Early rehabilitation and the limited use of sedatives might mitigate the severity of this syndrome.

The effect of acute kidney injury on long-term health-related quality of life: a prospective follow-up study.

INTRODUCTION: Acute kidney injury (AKI) is a serious complication in critically ill patients admitted to the Intensive Care Unit (ICU). We hypothesized that ICU survivors with AKI would have a worse health-related quality of life (HRQOL) outcome than ICU survivors without AKI. METHODS: We performed a long-term prospective observational study. Patients admitted for > 48 hours in a medical-surgical ICU were included and divided in two groups: patients who fulfilled RIFLE criteria for AKI and patients without AKI. We used the Short-Form 36 to evaluate HRQOL before admission (by proxy within 48 hours after admission of the patient), at ICU discharge, hospital discharge, 3 and 6 months following ICU discharge (all by patients). Recovery in HRQOL from ICU-admission onwards was assessed using linear mixed modelling. RESULTS: Between September 2000 and January 2007 all admissions were screened for study participation. We included a total of 749 patients. At six months after ICU discharge 73 patients with AKI and 325 patients without AKI could be evaluated. In survivors with and without AKI, the pre-admission HRQOL (by proxy) and at six months after ICU discharge was significantly lower compared with an age matched general population. Most SF-36 dimensions changed significantly over time from ICU discharge. Change over time of HRQOL between the different AKI Rifle classes (Risk, Injury, Failure) showed no significant differences. At ICU discharge, scores were lowest in the group with AKI compared with the group without AKI for the physical functioning, role-physical and general health dimensions. However, there were almost no differences in HRQOL between both groups at six months. CONCLUSIONS: The pre-admission HRQOL (by proxy) of AKI survivors was significantly lower in two dimensions compared with the age matched general population. Six months after ICU discharge survivors with and without AKI showed an almost similar HRQOL. However, compared with the general population with a similar age, HRQOL was poorer in both groups.

[A man who could only sleep sitting]. / Een man die alleen zittend kan slapen.

Bilateral diaphragm paralysis is a serious condition causing failure to sleep in the supine position and this condition often results into severe hypercapnia leading to respiratory failure. Here we describe two cases that required mechanical ventilation, and subsequently failed to respond to intermittent non-invasive ventilation. Subjects were successfully taken from mechanical ventilation after unilateral plication of a hemidiafragm and one of them further improved after plication of the contralateral paralysed diaphragm. Remarkably, decompression of the left lower lung lobe after 20 years of lobar atelectasis resulted in rapid improvement of ventilation and gas exchange.

Sleep disturbances and sedation practices in the intensive care unit--a postal survey in the Netherlands.

BACKGROUND: Sleep disturbances are common in critically ill patients treated in the intensive care unit (ICU) with possible serious consequences. OBJECTIVE: The aim of this study was to get insight into sleeping and sedation practices in the adult ICUs in the Netherlands and survey which factors are important with respect to sleep in critically ill patients in the ICU. METHOD: A multi-centre, exploratory survey sent via mail to nurse managers of all adult ICUs in the Netherlands. RESULTS: Interventions without medication to improve the sleep of the critically ill patients were mostly defined as keeping patients awake during the day (94.2%), reducing noise of the ICU staff (89.7%) and reducing nursing interventions at night (86.8%). None of the ICUs used a sleep questionnaire. Nursing autonomy regarding sleep and sedation practices for patients (rated on a 10-point numerical scale) was judged as moderate (median 5, interquartile range (IQR) 3-7). How often nursing observations influence sleeping practices in the ICU was judged as good (median 8, IQR 7-8). How the average ICU patient was sleeping was judged as moderately well (median 6, IQR 5-7). Most intensive care units (83.8%) did not have a sleeping protocol, but 67.6% of these intensive care units suggested they should implement a sleeping protocol. CONCLUSIONS: The average critically ill patient has sleep disturbances, that is, is sleeping moderately well according to nurses' views and opinions, mostly due to a disturbed sleep-awake cycle, delirium and nursing interventions. Intensive care nurses perceive only a moderate feeling of autonomy and influence regarding the management of sleeping practices.

Changes of health-related quality of life in critically ill octogenarians: a follow-up study.

BACKGROUND: Intensivists frequently are concerned about whether octogenarians actually will benefit from ICU admission. We studied changes in health-related quality of life (HRQOL) 6 months following ICU discharge in those patients. METHODS: We performed a long-term prospective study in a medical-surgical ICU. Patients aged ≥ 80 years (n = 129) and < 80 years (n = 620) admitted for > 48 h were included. We used the Medical Outcomes Study 36-item short form (SF-36) to evaluate HRQOL before ICU admission (using proxies), at ICU discharge, at hospital discharge, and at 3 and 6 months following ICU discharge, using a linear mixed model. RESULTS: At 6 months after ICU discharge, 49 patients aged ≥ 80 years and 352 patients aged < 80 years could be evaluated. At ICU discharge, physical functioning was far lower than mental functioning (physical component score, 24.9; mental component score, 46.1) in the octogenerians. Most SF-36 dimensions showed significant improvement over time (all P < .01, except role-emotional [P = .038] and bodily pain [P = .77]). In the octogenarians, mean SF-36 scores 6 months after ICU discharge were comparable to baseline in all dimensions. Most dimensions of the SF-36 were not significantly lower in surviving octogenarians at 6 months after ICU discharge compared with the normal population. CONCLUSIONS: We demonstrated a good recovery of HRQOL in octogenarians surviving critical illness. The findings suggest that denying admission to the ICU should not just rely on old age.

The Academic Medical Center Linear Disability Score for evaluation of physical reserve on admission to the ICU: can we query the relatives?

INTRODUCTION: Evaluating the pre-morbid functional status in critically ill patients is important and frequently done using the physical component score (PCS) of the Short Form 36, although this approach has its limitations. The Academic Medical Center Linear Disability Score (ALDS) is a recently developed generic item bank used to measure the disability status of patients with a broad range of diseases. We aimed to study whether proxy scoring with the ALDS could be used to assess the patients' functional status on admission for cardiac care unit (CCU) or ICU patients and how the ALDS relates to the PCS using the Short Form 12 (SF-12). METHODS: Patients and proxies completed the ALDS and SF-12 score in the first 72 hours following ICU scheduled surgery (n = 14), ICU emergency admission (n = 56) and CCU emergency admission (n = 70). RESULTS: In all patients (n = 140) a significant intra-class correlation was found for the ALDS (0.857), the PCS (0.798) and the mental component score (0.679) between patients and their proxy. In both scheduled and emergency admissions, a significant correlation was found between patients and their proxy for the ALDS, although the lowest correlation was found for the ICU scheduled admissions (0.755) compared with the ICU emergency admissions (0.889). In CCU patients, the highest significant correlation between patients and proxies was found for the ALDS (0.855), for the PCS (0.807) and for the mental component score (0.740). CONCLUSIONS: Relatives in close contact with critically ill patients can adequately reflect the patient's level of disability on ICU and CCU admission when using the ALDS item bank, which performed at least as well as the PCS. The ALDS could therefore be a useful alternative for the PCS of the SF-12.

Survey into bereavement of family members of patients who died in the intensive care unit.

BACKGROUND: The death of a family member in the intensive care unit (ICU) is often sudden and unexpected and may have a strong impact on family members. OBJECTIVE: To describe the characteristics of bereavement, to find out if there is a need for follow-up bereavement service and to determine if the information and care in the ICU is sufficient for relatives of deceased ICU patients. METHODS: An exploratory cross-sectional study using a structured telephone interview in 51 relatives, in a 10 bed adult mixed medical-surgical ICU. Respondents were selected according to three criteria; (1) their relative had died between June 2008 and June 2009 in the ICU, (2) they were involved during the ICU stay preceding death and (3) had sufficient knowledge of the Dutch language. RESULTS: A majority (77%) was satisfied with the delivered ICU-care and the information provided. Most common complaints concerned communication and the information provided. Almost all the respondents (90%) understood the fatal sequence of events during the dying process. Subsequently, a substantial portion of the respondents (37%) complained about 'sleeping problems'. The need for a follow-up bereavement service was reported by 35% of the respondents. CONCLUSIONS: Despite a high level of satisfaction with the care provided in the ICU many respondents considered a follow-up bereavement service potentially useful to deal with the death of the family member and to get remaining questions answered.

Accumulation of advanced glycation end (AGEs) products in intensive care patients: an observational, prospective study.

BACKGROUND: Oxidative stress plays an important role in the course and eventual outcome in a majority of patients admitted to the intensive care unit (ICU). Markers to estimate oxidative stress are not readily available in a clinical setting. AGEs accumulation has been merely described in chronic conditions, but can also occur acutely due to oxidative stress. Since AGEs have emerged to be stable end products, these can be a marker of oxidative stress. Skin autofluorescence (AF) is a validated marker of tissue content of AGEs. We hypothesized that AGEs accumulate acutely in ICU patients. METHODS: We performed an observational prospective study in a medical surgical ICU in a university affiliated teaching hospital. All consecutively admitted ICU patients in a 2 month period were included. Skin AF was measured using an AGE reader in 35 consecutive ICU patients > 18 yrs. As a comparison, historical data of a control group (n = 231) were used. These were also used to calculate age-adjusted AF-levels (AFadj). Values are expressed as median and interquartile range [P25-P75]. Differences between groups were tested by non parametric tests. P < 0.05 was considered statistically significant. RESULTS: AFadj values were higher in ICU patients (0.33 [0.00 - 0.68]) than in controls (-0.07 [-0.29 - 0.24]; P < 0.001). No differences in skin AFadj were observed between acute or planned admissions, or presence of sepsis, nor was skin AFadj related to severity of disease as estimated by APACHE-II score, length of ICU, hospital stay or mortality. CONCLUSION: Acute AGE accumulation in ICU patients was shown in this study, although group size was small. This can possibly reflect oxidative stress in ICU patients. Further studies should reveal whether AGE-accumulation will be a useful parameter in ICU patients and whether skin AF has a predictive value for outcome, which was not shown in this small study.

The practice of and documentation on withholding and withdrawing life support: a retrospective study in two Dutch intensive care units.

OBJECTIVE: We determined how often life support was withheld or withdrawn in patients who died in the intensive care unit (ICU) or early after ICU discharge and evaluated documentation on decisions regarding these changes in life support orders. METHODS: This was a retrospective study in a university hospital and a general teaching hospital. Charts of patients who died during ICU stay or within 7 days after ICU discharge in 2005 were reviewed. RESULTS: Of 2578 admitted patients, 356 patients (14%) died either in the ICU or within 7 days after ICU discharge. For 9 patients data were missing, leaving 347 patients for analysis. Seventy-seven patients (22%) died with full life support, 85 (25%) died while treatment was being withheld, and 185 (53%) patients died while treatment was being withdrawn. One or more changes in life support orders were noted in 266 patients (77%). Only 8% of the patients were recorded to be incapacitated at the time of the change. Patients' preferences regarding life support were documented in less than one-quarter of cases. In approximately one third of cases, it was not documented which member(s) of the ICU team were involved in an end-of-life decision. In the documented cases, end-of-life decisions were made along with the patient (7%) or with the patient's representatives (59%). CONCLUSION: ICU nonsurvivors and patients who die shortly after ICU discharge predominantly die with orders to withhold or withdraw life support. Documentation on the decisions to forgo full life support is poor.

Health-related quality of life in critically ill patients: how to score and what is the clinical impact?

PURPOSE OF REVIEW: Traditionally, the assessment of critical care has focused largely on mortality. However, in the last few years, there is more attention on the quality of survival. Health-related quality of life (HRQOL) is an important issue for both patients and family. The purpose of this review is to describe HRQOL scoring in critically ill patients and to discuss the clinical impact on HRQOL. RECENT FINDINGS: Studies on the effect of critical illness on HRQOL show contradicting results. Several studies found that HRQOL at the time of discharge from hospital was impaired and that a gradual improvement occurred during follow-up, in some cases to preadmission hospital levels. Others show a full recovery to preadmission HRQOL. SUMMARY: In this article, we reviewed the methods and description of measurement instruments used in critically ill patients. The most recently used instruments to measure HRQOL, how to score HRQOL before ICU admission and the impact of critical illness on HRQOL are discussed. Assessment of HRQOL can improve the answers given by critical care physicians and nurses about the prospects of their patients. To get insights in these issues regarding the impact of ICU treatment, we should incorporate not only short-term outcomes, for example length of stay and mortality, but also HRQOL.

Off hour admission to an intensivist-led ICU is not associated with increased mortality.

INTRODUCTION: Caring for the critically ill is a 24-hour-a-day responsibility, but not all resources and staff are available during off hours. We evaluated whether intensive care unit (ICU) admission during off hours affects hospital mortality. METHODS: This retrospective multicentre cohort study was carried out in three non-academic teaching hospitals in the Netherlands. All consecutive patients admitted to the three ICUs between 2004 and 2007 were included in the study, except for patients who did not fulfil APACHE II criteria (readmissions, burns, cardiac surgery, younger than 16 years, length of stay less than 8 hours). Data were collected prospectively in the ICU databases. Hospital mortality was the primary endpoint of the study. Off hours was defined as the interval between 10 pm and 8 am during weekdays and between 6 pm and 9 am during weekends. Intensivists, with no responsibilities outside the ICU, were present in the ICU during daytime and available for either consultation or assistance on site during off hours. Residents were available 24 hours a day 7 days a week in two and fellows in one of the ICUs. RESULTS: A total of 6725 patients were included in the study, 4553 (67.7%) admitted during daytime and 2172 (32.3%) admitted during off hours. Baseline characteristics of patients admitted during daytime were significantly different from those of patients admitted during off hours. Hospital mortality was 767 (16.8%) in patients admitted during daytime and 469 (21.6%) in patients admitted during off hours (P < 0.001, unadjusted odds ratio 1.36, 95%CI 1.20-1.55). Standardized mortality ratios were similar for patients admitted during off hours and patients admitted during daytime. In a logistic regression model APACHE II expected mortality, age and admission type were all significant confounders but off-hours admission was not significantly associated with a higher mortality (P = 0.121, adjusted odds ratio 1.125, 95%CI 0.969-1.306). CONCLUSIONS: The increased mortality after ICU admission during off hours is explained by a higher illness severity in patients admitted during off hours.

Changes in the volume status of haemodialysis patients are reflected in sublingual microvascular perfusion.

BACKGROUND: After the introduction of sidestream darkfield imaging (SDF) of the microcirculation, it has become clear that in sepsis, microcirculatory alterations can exist in the absence of systemic haemodynamic abnormalities. However, it is unclear whether this phenomenon also occurs in the treatment of end-stage kidney disease (ESKD) where alterations in the volume status of patients occur during dialysis. We tested the hypothesis that volume changes during dialysis directly affect the perfusion of the microcirculation in a group of adult haemodialysis patients. Secondly, we evaluated microcirculatory response to autotransfusion using the Trendelenburg position (TP). METHODS: Patients who were on chronic intermittent haemodialysis were assessed for sublingual microvascular flow by SDF imaging pre- and post-TP, performed before and after ultrafiltration (UF). Sublingual microvascular flow was estimated using a semi-quantitative microvascular flow index (MFI) in small (diameter <25 microm, which includes capillaries), medium (25-50 microm) and large-sized (50-100 microm) microvessels (no flow: 0, intermittent flow: 1, sluggish flow: 2 and continuous flow: 3). Changes were evaluated with the non-parametric paired Wilcoxon test. P < 0.05 was judged to indicate a significant difference. RESULTS: Thirty-nine adult patients took part in the study. The underlying diseases causing ESKD were predominantly hypertension (HT, n = 10), diabetes mellitus (DM, n = 7) or both (n = 3). At the start of UF, microvascular flow did not change significantly by TP. After completion of UF, MFI had decreased significantly in all types of microvessels (P < 0.001). After UF (median volume extraction 2.49l), MFI was lower than that at the start of UF and increased in most patients after TP (P < 0.001) in all categories of vessels. Changes were most prominent in the smallest microvessels. CONCLUSIONS: Sublingual microvascular perfusion is reduced by UF and can be restored temporarily using autotransfusion by TP due to increased venous return. SDF imaging is able to detect these volume changes. SDF imaging and TP could become a useful bedside tool to evaluate the patient's (microvascular) volume status and response to therapy in dialysis or intradialytic hypotension.

Limitations and practicalities of CAM-ICU implementation, a delirium scoring system, in a Dutch intensive care unit.

BACKGROUND: Delirium is a frequently missed diagnosis in the intensive care unit (ICU). Implementation of the Confusion Assessment Method for the ICU (CAM-ICU) may improve recognition of delirium. However, the ICU team may be reluctant to adopt daily assessment by a screening tool. This report focusses on the obstacles and barriers encountered with respect to organisational context and prevailing opinions and attitudes when implementing the CAM-ICU in daily practice in a Dutch ICU. METHODS: A structured implementation process was set up comprising four phases: (1) assessing the current situation to understand behaviour towards delirium; (2) the identification of barriers to the implementation of the CAM-ICU; (3) preparation of the ICU team for a change in attitude; and (4) evaluation of the effects of implementation. RESULTS: Phase 1 demonstrated that there was no delirium protocol available; it was left to the attending physicians when and how to diagnose delirium in each individual patient. In addition, nurses acted on delirium in a non-structured way; nurses thought implementation of the CAM-ICU would be very time-consuming and would not add to their ability in recognising delirium. In Phase 2, several barriers to implementation were addressed. Firstly, all nurses had to be convinced that delirium is an important problem and, secondly, logistics had to be put in place, for example, picture cards at every bedside, communication between daily nurses and a delirium working group had to be improved. In Phase 3, 10 nurses were educated to perform the CAM-ICU through several training sessions which included videos to illustrate different delirium states; these trained nurses educated all other nurses. A check box in the daily records was introduced to denote whether the CAM-ICU had been performed. In Phase 4, after a training period and 2 months of actual routine bedside CAM-ICU performance, evaluation demonstrated that frequency of assessments on un-sedated patients had increased from 38% to 95% per nursing shift. A short survey amongst the ICU nurses also showed that awareness of delirium and appreciation of the clinical problem had markedly increased. CONCLUSION: Implementation of the CAM-ICU in daily critical care is feasible. A structural training programme is probably helpful for success of implementation.

Occurrence of delirium is severely underestimated in the ICU during daily care.

OBJECTIVE: Delirium is associated with prolonged intensive care unit (ICU) stay and higher mortality. Therefore, the recognition of delirium is important. We investigated whether intensivists and ICU nurses could clinically identify the presence of delirium in ICU patients during daily care. METHODS: All ICU patients in a 3-month period who stayed for more than 48 h were screened daily for delirium by attending intensivists and ICU nurses. Patients were screened independently for delirium by a trained group of ICU nurses who were not involved in the daily care of the patients under study. The Confusion Assessment Method for the ICU (CAM-ICU) was used as a validated screening instrument for delirium. Values are expressed as median and interquartile range (IQR; P25-P75). RESULTS: During the study period, 46 patients (30 male, 16 female), median age 73 years (IQR = 64-80), with an ICU stay of 6 days (range 4-11) were evaluated. CAM-ICU scores were obtained during 425 patient days. Considering the CAM-ICU as the reference standard, delirium occurred in 50% of the patients with a duration of 3 days (range 1-9). Days with delirium were poorly recognized by doctors (sensitivity 28.0%; specificity 100%) and ICU nurses (sensitivity 34.8%; specificity 98.3%). Recognition did not differ between hypoactive or active status of the patients involved. CONCLUSION: Delirium is severely under recognized in the ICU by intensivists and ICU nurses in daily care. More attention should be paid to the implementation of a validated delirium-screening instrument during daily ICU care.

Prognostic value of blood lactate levels: does the clinical diagnosis at admission matter?

BACKGROUND: Hyperlactatemia and its reduction after admission in the intensive care unit (ICU) have been related to survival. Because it is unknown whether this equally applies to different groups of critically ill patients, we compared the prognostic value of repeated lactate levels (a) in septic patients versus patients with hemorrhage or other conditions generally associated with low-oxygen transport (LT) (b) in hemodynamically stable versus unstable patients. METHODS: In this prospective observational two-center study (n = 394 patients), blood lactate levels at admission to the ICU (Lac(T0)) and the reduction of lactate levels from T = 0 to T = 12 hours (DeltaLac(T0-12)) and from T = 12 to T = 24 hours (DeltaLac(T12-24)), were related to in-hospital mortality. RESULTS: Reduction of lactate was associated with a lower mortality only in the sepsis group (DeltaLac(T0-12): hazard ratio [HR] 0.34, p = 0.004 and DeltaLac(T12-24): HR 0.24, p = 0.003), but not in the LT group (DeltaLac(T0-12); HR 0.78, p = 0.52 and DeltaLac(T12-24); HR 1.30, p = 0.61). The prognostic values of Lac(T0), DeltaLac(T0-12), and DeltaLac(T12-24) were similar in hemodynamically stable and unstable patients (p = 0.43). CONCLUSIONS: Regardless of the hemodynamic status, lactate reduction during the first 24 hours of ICU stay is associated with improved outcome only in septic patients, but not in patients with hemorrhage or other conditions generally associated with LT. We hypothesize that in this particular group a reduction in lactate is not associated with improved outcome due to irreversible damage at ICU admission.