Patient-reported physical functioning is limited in almost half of critical illness survivors 1-year after ICU-admission: A retrospective single-centre study.

Post-intensive care unit (ICU) sequelae, including physical and mental health problems, are relatively unexplored. Characteristics commonly used to predict outcome lack prognostic value when it comes to long-term physical recovery. Therefore, the objective of this study was to assess the incidence of non-recovery in long-stay ICU-patients. In this single-centre study, retrospective data of adults with an ICU stay >48 hours who visited the specialized post-ICU clinic, and completed the Dutch RAND 36-item Short Form questionnaire at 3 and 12 months post-ICU, were retrieved from electronic patient records. In cases where physical functioning scores at 12 months were below reference values, patients were allocated to the physical non-recovery (NR) group. Significantly different baseline and (post-)ICU-characteristics were assessed for correlations with physical recovery at 12 months post-ICU. Of 250 patients, 110 (44%) fulfilled the criteria for the NR-group. Neither the severity of illness, type of admission, nor presence of sepsis did not differ between groups. However, NR-patients had a higher age, were more often female, and had a higher incidence of co-morbidities. Shorter LOS ICU, lower incidence of medical comorbidities, and better physical performance at 3 months were significantly correlated with 1-year physical recovery. Comorbidities and reduced physical functioning at 3 months were identified as independent risk-factors for long-term physical non-recovery. In conclusion, a substantial proportion of long-stay ICU-patients who visited the standard care post-ICU clinic did not fulfil the criteria for full physical recovery at 12 months post-ICU. Commonly used ICU-characteristics, such as severity of illness, do not have sufficient prognostic value when it comes to long-term recovery of health-related quality of life.

Elevated C-reactive protein levels at ICU discharge as a predictor of ICU outcome: a retrospective cohort study.

BACKGROUND: Before discharging a patient from the ICU, an adequate patient evaluation is needed to detect individuals as high risk for unfavorable outcome. A pro- or anti-inflammatory status is a potential risk factor for an adverse outcome, and elevated CRP concentrations have shown to correlate with organ failure. Several studies have been performed to evaluate the use of CRP as a marker of post-ICU prognosis. Results are seemingly conflicting, and it is worthwhile to investigate these markers further as CRP is an adequate marker of pro- and anti-inflammatory status of the patient. We aimed to test the hypothesis that elevated CRP levels at ICU discharge are associated with an increased risk of ICU readmission and in-hospital mortality in patients with a prolonged ICU stay. METHODS: A retrospective cohort study was performed in a single-center hospital with an 18-bed mixed medical/surgical ICU. Patients discharged alive from the ICU with at least 48-h ICU length of stay were evaluated. Patients were distributed into two groups: 'high CRP' (≥75 mg/L) and 'low CRP' (<75 mg/L) at ICU discharge. We assessed the difference in adverse outcome (ICU readmission and/or in-hospital mortality) between these groups. RESULTS: A total of 998 patients were included. Compared to the 'low CRP' group, patients in the 'high CRP' group had a higher readmission rate (13.1 vs. 7.4 %; p = 0.003). The post-ICU mortality rate in the 'high CRP' group and 'low CRP' group was 6.9 % and 4.7 %, respectively; p = 0.127. Combined readmission and mortality rates were significantly higher in the 'high CRP' group in comparison with the 'low CRP' group (17.9 vs. 10.1 %; p = 0.001). Hospital mortality in patients readmitted to the ICU was significantly higher than in non-readmitted patients (20 vs. 4.3 %; p < 0.001). Strikingly, the 'high CRP' group had significantly lower APACHE II and SOFA scores at ICU admission compared to the 'low CRP' group. This highlights the potential for ICU-acquired risk factors, including CRP. CONCLUSIONS: A high CRP concentration (≥75 mg/L) within 24 h before ICU discharge is associated with an increased risk of adverse outcome post-ICU discharge. However, CRP at discharge represents only a very moderate risk factor and may not be used for individual clinical decision-making.

Coma after overdose with duloxetine.

OBJECTIVE: To describe a case of a patient who became comatose after taking an overdose of duloxetine, a serotonin-norepinephrine reuptake inhibitor. CASE SUMMARY: A 49-year-old male ingested an overdose of duloxetine approximately 2 hours before presentation to the emergency department. On arrival he was drowsy, but easily awakened and oriented, with Glasgow Coma Score 14 (eyes 3, motor 6, verbal 5). Immediately after admission, charcoal and magnesium sulfate were given to prevent further systemic absorption of medication through the gastrointestinal tract. No gastric lavage was performed. Six hours after drug intake the patient became unconscious (Glasgow Coma Score 7, eyes 2, motor 4, verbal 1). Full toxicologic screening showed a toxic duloxetine plasma concentration of 0.86 mg/L. The patient was admitted to the intensive care unit (ICU) and, on arrival, urinary retention was noted. During ICU admission the patient remained hemodynamically stable; approximately 12 hours after ingestion of duloxetine, he regained consciousness. Over the next 3 days the urinary output decreased to 60 mL/day. After 4 days patient was discharged without any remaining symptoms. Based on repeated plasma duloxetine serum concentration determinations, a plasma half-life of duloxetine was calculated to be 18 hours (reference range 9-19). DISCUSSION: The Naranjo probability scale suggested that duloxetine was the probable cause for the symptoms described. CONCLUSION: Overdose with duloxetine can induce coma several hours after intake, with a fast reversal in our case.