Implementing a Serious Illness Risk Prediction Model: Impact on Goals of Care Documentation.

CONTEXT: Goals of care conversations can promote high value care for patients with serious illness, yet documented discussions infrequently occur in hospital settings. OBJECTIVES: We sought to develop a quality improvement initiative to improve goals of care documentation for hospitalized patients. METHODS: Implementation occurred at an academic medical center in Pittsburgh, Pennsylvania. Intervention included integration of a 90-day mortality prediction model grouping patients into low, intermediate, and high risk; a centralized goals of care note; and automated notifications and targeted palliative consults. We compared documented goals of care discussions by risk score before and after implementation. RESULTS: Of the 12,571 patients hospitalized preimplementation and 10,761 postimplementation, 1% were designated high risk and 11% intermediate risk of mortality. Postimplementation, goals of care documentation increased for high (17.6%-70.8%, P< 0.0001) and intermediate risk patients (9.6%-28.0%, P < 0.0001). For intermediate risk patients, the percentage of goals of care documentation performed by palliative medicine specialists increased from pre- to postimplementation (52.3%-71.2%, P = 0.0002). For high-risk patients, the percentage of goals of care documentation completed by the primary service increased from pre-to postimplementation (36.8%-47.1%, P = 0.5898, with documentation performed by palliative medicine specialists slightly decreasing from pre- to postimplementation (63.2%-52.9%, P = 0.5898). CONCLUSIONS: Implementation of a goals of care initiative using a mortality prediction model significantly increased goals of care documentation especially among high-risk patients. Further study to assess strategies to increase goals of care documentation for intermediate risk patients is needed especially by nonspecialty palliative care.

Peripherally Infused Norepinephrine to Avoid Central Venous Catheter Placement in a Medical Intensive Care Unit: A Pilot Study.

BACKGROUND: Reducing central venous catheter (CVC) utilization can reduce complications in the intensive care unit (ICU). While norepinephrine (NE) is traditionally administered via a CVC, lower concentrations may be safely administered via peripheral intravenous (PIV) lines. OBJECTIVE: We aimed to describe the implementation of a pilot protocol utilizing PIVs to administer a low-dose and lower-concentration NE, review the number of CVCs avoided, and evaluate any adverse events. METHODS: In a quaternary medical intensive care unit (MICU), from March 1, 2019, to February 29, 2020, we reviewed charts for CVC placement and adverse events from the pNE infusion. We also measured unit-level CVC utilization in all MICU patients and assessed the change in utilization associated with the peripheral norepinephrine (pNE) protocol. RESULTS: Over a 1-year period, 87 patients received a pNE infusion. Overall, 44 patients (51%) never required CVC placement during their MICU stay. Three patients (3%) experienced adverse events, none of which were documented as serious and or required antidote for treatment. Implementation of the protocol was associated with a decrease in the number of patients at the unit level who received CVCs, even if they did not receive pNE. CONCLUSION AND RELEVANCE: In this small pilot study, we pragmatically demonstrated that pNE is safe and may reduce the need for CVC placement. This information can be used to aid in pNE protocol development and implementation at other institutions, but further research should be done to confirm the safety of routine use of pNE in clinical practice.

Comparison of three cisatracurium dosing strategies in acute respiratory distress syndrome: A focus on drug utilization and improvement in oxygenation.

PURPOSE: Three continuous dosing strategies of cisatracurium (CIS) for acute respiratory distress syndrome (ARDS) have been described in the literature. After implementation of a ventilator synchrony protocol (VSP), we sought to determine which continuous CIS dosing strategy utilized the least amount of drug without compromising efficacy. METHODS: We retrospectively reviewed patients with ARDS receiving continuous CIS from January 1, 2013 to December 31, 2018. We categorized patients into one of three dosing strategies: fixed dose (FD), titration based solely on train-of-four (TOF), or the VSP. We documented drug consumption and determined efficacy by comparing the change in PaO2/FiO2 ratio (P/F) and oxygenation index (OI) from baseline up to 48 h. RESULTS: A total of 1047 patients were screened, and 189 met inclusion criteria (VSP = 69, TOF = 99, FD = 21). Drug consumption (mg) was significantly lower in the VSP arm: 415 [IQR 318-528] compared to both the TOF: 665 [IQR 472-927] and the FD arms: 1730 [IQR 1695-1800], p < 0.001 for each. The change in P/F and OI from baseline were statistically equivalent at all time points. CONCLUSION: Without impacting efficacy of gas exchange, a protocol using ventilator synchrony for CIS titration required significantly less drug compared to TOF-based titration and a fixed dosing regimen.

A Quality Improvement Evaluation of a Primary As-Needed Light Sedation Protocol in Mechanically Ventilated Adults.

OBJECTIVES: First, to implement successfully a light-sedation protocol, favoring initial as-needed (prioritizing as-needed) boluses over continuous infusion sedation, and second, to evaluate if this protocol was associated with differences in patient-level sedative requirements, clinical outcomes, and unit-level longitudinal changes in pharmacy charges for sedative medications. DESIGN: Retrospective review comparing patients who received the prioritizing as-needed sedation protocol to similar patients eligible for the prioritizing as-needed protocol but treated initially with continuous infusion sedation. SETTING: Thirty-two bed medical ICUs in a large academic medical center. PATIENTS: A total of 254 mechanical ventilated patients with a target Riker Sedation-Agitation Scale goal of 3 or 4 were evaluated over a 2-year period. Of the evaluable patients, 114 received the prioritizing as-needed sedation protocol and 140 received a primary continuous infusion approach. INTERVENTIONS: A multidisciplinary leadership team created and implemented a light-sedation protocol, focusing on avoiding initiation of continuous sedative infusions and prioritizing prioritizing as-needed sedation. MEASUREMENTS AND MAIN RESULTS: Overall, 42% of patients in the prioritizing as-needed group never received continuous infusion sedation. Compared with the continuous infusion sedation group, patients treated with the prioritizing as-needed protocol received significantly less opioid, propofol, and benzodiazepine. Patients in the prioritizing as-needed group experienced less delirium, shorter duration of mechanical ventilation, and shorter ICU length of stay. Adverse events were similar between the two groups. At the unit level, protocol implementation was associated with reductions in the use of continuous infusion sedative medications. CONCLUSIONS: Implementation and use of a prioritizing as-needed protocol targeting light sedation appear to be safe and effective. These single-ICU retrospective findings require wider, prospective validation.

Treatment with allogeneic mesenchymal stromal cells for moderate to severe acute respiratory distress syndrome (START study): a randomised phase 2a safety trial.

BACKGROUND: Treatment with bone-marrow-derived mesenchymal stromal cells (MSCs) has shown benefits in preclinical models of acute respiratory distress syndrome (ARDS). Safety has not been established for administration of MSCs in critically ill patients with ARDS. We did a phase 2a trial to assess safety after administration of MSCs to patients with moderate to severe ARDS. METHODS: We did a prospective, double-blind, multicentre, randomised trial to assess treatment with one intravenous dose of MSCs compared with placebo. We recruited ventilated patients with moderate to severe ARDS (ratio of partial pressure of oxygen to fractional inspired oxygen <27 kPa and positive end-expiratory pressure [PEEP] ≥8 cm H2O) in five university medical centres in the USA. Patients were randomly assigned 2:1 to receive either 10 × 106/kg predicted bodyweight MSCs or placebo, according to a computer-generated schedule with a variable block design and stratified by site. We excluded patients younger than 18 years, those with trauma or moderate to severe liver disease, and those who had received cancer treatment in the previous 2 years. The primary endpoint was safety and all analyses were done by intention to treat. We also measured biomarkers in plasma. MSC viability was tested in a post-hoc analysis. This trial is registered with ClinicalTrials.gov, number NCT02097641. FINDINGS: From March 24, 2014, to Feb 9, 2017 we screened 1038 patients, of whom 60 were eligible for and received treatment. No patient experienced any of the predefined MSC-related haemodynamic or respiratory adverse events. One patient in the MSC group died within 24 h of MSC infusion, but death was judged to be probably unrelated. 28-day mortality did not differ between the groups (30% in the MSC group vs 15% in the placebo group, odds ratio 2·4, 95% CI 0·5-15·1). At baseline, the MSC group had numerically higher mean scores than the placebo group for Acute Physiology and Chronic Health Evaluation III (APACHE III; 104 [SD 31] vs 89 [33]), minute ventilation (11·1 [3·2] vs 9·6 [2·4] L/min), and PEEP (12·4 [3·7] vs 10·8 [2·6] cm H2O). After adjustment for APACHE III score, the hazard ratio for mortality at 28 days was 1·43 (95% CI 0·40-5·12, p=0·58). Viability of MSCs ranged from 36% to 85%. INTERPRETATION: One dose of intravenous MSCs was safe in patients with moderate to severe ARDS. Larger trials are needed to assess efficacy, and the viability of MSCs must be improved. FUNDING: National Heart, Lung, and Blood Institute.

Measuring associations between the microbiota and repeated measures of continuous clinical variables using a lasso-penalized generalized linear mixed model.

BACKGROUND: Human microbiome studies in clinical settings generally focus on distinguishing the microbiota in health from that in disease at a specific point in time. However, microbiome samples may be associated with disease severity or continuous clinical health indicators that are often assessed at multiple time points. While the temporal data from clinical and microbiome samples may be informative, analysis of this type of data can be problematic for standard statistical methods. RESULTS: To identify associations between microbiota and continuous clinical variables measured repeatedly in two studies of the respiratory tract, we adapted a statistical method, the lasso-penalized generalized linear mixed model (LassoGLMM). LassoGLMM can screen for associated clinical variables, incorporate repeated measures of individuals, and address the large number of species found in the microbiome. As is common in microbiome studies, when the number of variables is an order of magnitude larger than the number of samples LassoGLMM can be imperfect in its variable selection. We overcome this limitation by adding a pre-screening step to reduce the number of variables evaluated in the model. We assessed the use of this adapted two-stage LassoGLMM for its ability to determine which microbes are associated with continuous repeated clinical measures.We found associations (retaining a non-zero coefficient in the LassoGLMM) between 10 laboratory measurements and 43 bacterial genera in the oral microbiota, and between 2 cytokines and 3 bacterial genera in the lung. We compared our associations with those identified by the Wilcoxon test after dichotomizing our outcomes and identified a non-significant trend towards differential abundance between high and low outcomes. Our two-step LassoGLMM explained more of the variance seen in the outcome of interest than other variants of the LassoGLMM method. CONCLUSIONS: We demonstrated a method that can account for the large number of genera detected in microbiome studies and repeated measures of clinical or longitudinal studies, allowing for the detection of strong associations between microbes and clinical measures. By incorporating the design strengths of repeated measurements and a prescreening step to aid variable selection, our two-step LassoGLMM will be a useful analytic method for investigating relationships between microbes and repeatedly measured continuous outcomes.

Home discharge following critical illness: A qualitative analysis of family caregiver experience.

BACKGROUND: Few studies have longitudinally explored the experience and needs of family caregivers of ICU survivors after patients' home discharge. METHODS: Qualitative content analysis of interviews drawn from a parent study that followed family caregivers of adults ICU survivors for 4 months post-ICU discharge. RESULTS: Family caregivers (n = 20, all white, 80% woman) viewed home discharge as positive progress, but reported having insufficient time to transition from family visitor to the active caregiver role. Caregivers expressed feelings of relief during the steady recovery of family members' physical and cognitive function. However, the slow pace of improvement conflicted with their expectations. Even after patients achieved independent physical function, emotional needs persisted and these issues contributed to caregivers' anxiety, worry, and view that recovery was incomplete. CONCLUSION: Family caregivers of ICU survivors need information and skills to help managing patients' care needs, pacing expectations with actual patients' progress, and caregivers' health needs.

Clinical Outcomes and Mortality Impact of Hyperbaric Oxygen Therapy in Patients With Carbon Monoxide Poisoning.

OBJECTIVES: Carbon monoxide poisoning affects 50,000 per year in the United States alone. Mortality is approximately 3%, and up to 40% of survivors suffer from permanent neurocognitive and affective deficits. Hyperbaric oxygen therapy has shown benefit on reducing the long-term neurologic sequelae of carbon monoxide poisoning but has not demonstrated improved survival. The objective of this study is to assess the efficacy of hyperbaric oxygen for acute and long-term mortality in carbon monoxide poisoning using a large clinical databank. DESIGN: Retrospective analysis. SETTING: University of Pittsburgh Medical Center healthcare system (Pittsburgh, PA). PATIENTS: One-thousand ninety-nine unique encounters of adult patients with carbon monoxide poisoning. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Baseline demographics, laboratory values, hospital charge transactions, discharge disposition, and clinical information from charting were obtained from the electronic medical record. In propensity-adjusted analysis, hyperbaric oxygen therapy was associated with a reduction in inpatient mortality (absolute risk reduction, 2.1% [3.7-0.9%]; p = 0.001) and a reduction in 1-year mortality (absolute risk reduction, 2.1% [3.8-0.4%]; p = 0.013). CONCLUSIONS: These data demonstrate that hyperbaric oxygen is associated with reduced acute and reduced 1-year mortality. Further studies are needed on the mortality effects of hyperbaric oxygen therapy in carbon monoxide poisoning.

Referral to Palliative Care Infrequent in Patients with Idiopathic Pulmonary Fibrosis Admitted to an Intensive Care Unit.

BACKGROUND: Palliative care has been recommended as a means to assist patients with idiopathic pulmonary fibrosis (IPF) in managing symptom burden and advanced care planning. Timing of referral is important because although most patients display a gradually progressive course, a minority experience acute deterioration, an outcome associated with high mortality. AIM: To describe characteristics of IPF patients referred to a specialty lung disease center over a 10-year period who experienced acute deterioration and subsequent intensive care unit (ICU) admission, including frequency and timing of referral to palliative care. DESIGN: Retrospective review. SETTING/PARTICIPANTS: We identified 106 patients admitted to the ICU with acute deterioration due to a respiratory or nonrespiratory cause. Variables examined included demographics, date of first center visit, forced vital capacity, diffusing capacity of the lung for carbon monoxide (DLCO), and palliative care referral. RESULTS: ICU admission occurred early (median 9.5 months) and, for 34%, within four months of their first center visit. For nearly one-half of these patients, ICU admission occurred before their third clinic visit. Only 4 (3.8%) patients received a palliative care referral before ICU admission. The majority (77%) died during ICU admission. With exception of the relationship between DLCO% predicted at first visit and time to ICU admission (r = 0.32, p = 0.005), no variables identified those most likely to experience acute deterioration. CONCLUSION: Due to high mortality associated with ICU admission, patients and families should be informed about palliative care early following diagnosis of IPF.

Sleep in family caregivers of ICU survivors for two months post-ICU discharge.

OBJECTIVE: To describe changes in sleep quality in family caregivers of ICU survivors from the patients' ICU admission until two months post-ICU discharge. DESIGN: Descriptive repeated measure design. SETTING: Academic hospital medical ICU. MAIN OUTCOME MEASURES: Subjective sleep quality (Pittsburgh Sleep Quality Index [PSQI]) and objective sleep/wake variables (SenseWear Armband™) were measured in family caregivers at patients' ICU admission, within two weeks post-ICU discharge and two months post-ICU discharge. RESULTS: In 28 family caregivers of ICU survivors, most caregivers reported poor sleep quality (i.e. PSQI >5) across the three time points (64.3% during patients' ICU admission, 53.6% at each post-ICU time point). Worse trends in sleep quality and objective sleep/wake pattern were observed in caregivers who were employed, and a non-spouse. There were trends of worsening sleep quality in caregivers of patients unable to return home within two months post-ICU discharge compared to patients able to return home. CONCLUSIONS: Poor sleep quality was highly prevalent and persisted in family caregivers of ICU survivors for two months post-ICU discharge. Our data support the need for a larger longitudinal study to examine risk factors associated with sleep quality in family caregivers of ICU survivors to develop targeted interventions.

Association Between Train-of-Four Values and Gas Exchange Indices in Moderate to Severe Acute Respiratory Distress Syndrome.

BACKGROUND: Acute respiratory distress syndrome (ARDS) is associated with a mortality rate of approximately 40%. Neuromuscular blockade is associated with an improvement in oxygenation and a reduction in mortality in ARDS. OBJECTIVE: The goal of this evaluation was to determine if the depth of paralysis, determined by train-of-four (TOF) monitoring, correlates with gas exchange in moderate to severe ARDS. METHODS: This was a retrospective review of moderate to severe ARDS patients who were prescribed >12 hours of continuous infusion cisatracurium between January 1, 2013, and December 31, 2014, with a PaO2:FiO2 ratio <150 and documented TOF and arterial blood gases. Patients were evaluated for inclusion at 12, 24, and 48 hours after initiation of neuromuscular blockade. RESULTS: A total of 378 patients were screened for inclusion, with 107 evaluable patients meeting criteria at baseline. Poor correlation existed between TOF and oxygenation index (OI) at 12 (τ = 0.03), 24 (τ = 0.15) and 48 hours (τ = 0.08). When controlling for proning and baseline OI, the depth of paralysis did not have a significant effect on OI at 12, 24, or 48 hours. CONCLUSIONS: This evaluation demonstrates that the use of TOF monitoring for neuromuscular blockade does not correlate with gas exchange markers in moderate to severe ARDS.

Full Spectrum of LPS Activation in Alveolar Macrophages of Healthy Volunteers by Whole Transcriptomic Profiling.

Despite recent advances in understanding macrophage activation, little is known regarding how human alveolar macrophages in health calibrate its transcriptional response to canonical TLR4 activation. In this study, we examined the full spectrum of LPS activation and determined whether the transcriptomic profile of human alveolar macrophages is distinguished by a TIR-domain-containing adapter-inducing interferon-ß (TRIF)-dominant type I interferon signature. Bronchoalveolar lavage macrophages were obtained from healthy volunteers, stimulated in the presence or absence of ultrapure LPS in vitro, and whole transcriptomic profiling was performed by RNA sequencing (RNA-Seq). LPS induced a robust type I interferon transcriptional response and Ingenuity Pathway Analysis predicted interferon regulatory factor (IRF)7 as the top upstream regulator of 89 known gene targets. Ubiquitin-specific peptidase (USP)-18, a negative regulator of interferon α/ß responses, was among the top up-regulated genes in addition to IL10 and USP41, a novel gene with no known biological function but with high sequence homology to USP18. We determined whether IRF-7 and USP-18 can influence downstream macrophage effector cytokine production such as IL-10. We show that IRF-7 siRNA knockdown enhanced LPS-induced IL-10 production in human monocyte-derived macrophages, and USP-18 overexpression attenuated LPS-induced production of IL-10 in RAW264.7 cells. Quantitative PCR confirmed upregulation of USP18, USP41, IL10, and IRF7. An independent cohort confirmed LPS induction of USP41 and IL10 genes. These results suggest that IRF-7 and predicted downstream target USP18, both elements of a type I interferon gene signature identified by RNA-Seq, may serve to fine-tune early cytokine response by calibrating IL-10 production in human alveolar macrophages.

Psychological and Physical Health in Family Caregivers of Intensive Care Unit Survivors: Current Knowledge and Future Research Strategies.

PURPOSE: This article provides an overview of current knowledge on the impact of caregiving on the psychological and physical health of family caregivers of intensive care unit (ICU) survivors and suggestions for future research. METHODS: Review of selected papers published in English between January 2000 and October 2015 reporting psychological and physical health outcomes in family caregivers of ICU survivors. RESULTS: In family caregivers of ICU survivors followed up to five years after patients' discharge from an ICU, psychological symptoms, manifested as depression, anxiety and post-traumatic stress disorder, were highly prevalent. Poor self-care, sleep disturbances and fatigue were identified as common physical health problems in family caregivers. Studies to date are mainly descriptive; few interventions have targeted family caregivers. Further, studies that elicit unique needs of families from diverse cultures are lacking. CONCLUSION: Studies to date have described the impact of caregiving on the psychological and physical health in family caregivers of ICU survivors. Few studies have tested interventions to support unique needs in this population. Therefore, evidence for best strategies is lacking. Future research is needed to identify ICU caregivers at greatest risk for distress, time points to target interventions with maximal efficacy, needs of those from diverse cultures and test interventions to mitigate family caregivers' burden.

Depressive symptoms and anxiety in intensive care unit (ICU) survivors after ICU discharge.

BACKGROUND: The association between intensive care unit (ICU) survivors' psychological sequelae, individual care needs, and discharge disposition has not been evaluated. OBJECTIVE: To describe depressive symptoms and anxiety in ICU survivors and explore these symptoms based on individual care needs and discharge disposition for 4 months post-ICU discharge. METHODS: We analyzed data from 39 ICU survivors who self-reported measures of depressive symptoms (Center for Epidemiologic Studies-Depression 10 items [CESD-10]) and anxiety (Shortened Profile of Mood States-Anxiety subscale [POMS-A]). RESULTS: A majority of patients reported CESD-10 scores above the cut off (≥ 8) indicating risk for clinical depression. POMS-A scores were highest within 2 weeks post-ICU discharge and decreased subsequently. Data trends suggest worse depressive symptoms and anxiety when patients had moderate to high care needs and/or were unable to return home. CONCLUSION: ICU survivors who need caregiver assistance and extended institutional care reported trends of worse depressive symptoms and anxiety.

Fatigue in family caregivers of adult intensive care unit survivors.

CONTEXT: Family caregivers are a vital resource in the recovery of intensive care unit (ICU) survivors. Of concern, the stress associated with this role can negatively affect caregiver health. Fatigue, an important health indicator, has been identified as a predictor of various illnesses, greater use of health services, and early mortality. Examining the impact of fatigue on caregivers' physical health can assist in identifying critical time points and potential targets for intervention. OBJECTIVES: To describe self-reported fatigue in caregivers of ICU survivors from patients' ICU admission to ≤ 2 weeks, two- and four-months post-ICU discharge. METHODS: Patient-caregiver pairs were enrolled from a medical ICU. Caregiver fatigue was measured using the Short-Form 36 Health Survey Vitality subscale (SF-36 Vitality). Caregiver psychobehavioral stress responses included depressive symptoms, burden, health risk behaviors, and sleep quality. Patient data included self-reported physical symptoms and disposition (home vs. institution). RESULTS: Forty-seven patient-caregiver pairs were initially enrolled. Clinically significant fatigue (SF-36 Vitality ≤ 45) was reported by 43%-53% of caregivers across the time points, and these caregivers reported worse scores in measures of depressive symptoms, burden, health risk behaviors and sleep quality, and patients' symptom burden. In 26 caregivers with data for all time points (55% of the total sample), SF-36 Vitality scores showed trends of improvement when the patient returned home and greater impairment when institutionalization continued. CONCLUSION: In caregivers of ICU survivors, fatigue is common and potentially linked with poor psychobehavioral responses. Worsening fatigue was associated with greater symptom distress and long-term patient institutionalization.

Self-reported physical symptoms in intensive care unit (ICU) survivors: pilot exploration over four months post-ICU discharge.

CONTEXT: Survivors of critical illness must overcome persistent physical and psychological challenges. Few studies have longitudinally examined self-reported physical symptoms in intensive care unit (ICU) survivors. OBJECTIVES: To describe prevalence and severity of self-reported symptoms in 28 adult medical ICU survivors during the first four months post-ICU discharge and their associations with family caregiver responses. METHODS: Patients completed the Modified Given Symptom Assessment Scale. Caregivers completed the Shortened 10-item Center for Epidemiologic Studies Depression Scale, Brief Zarit Burden Score, Pittsburgh Sleep Quality Index, and the Caregiver Health Behavior form. Data at ICU discharge (two weeks or less), and two and four months post-ICU discharge were analyzed. RESULTS: Across the time points, most patients reported one or more symptoms (88.5-97%), with sleep disturbance, fatigue, weakness, and pain the most prevalent. For these four symptoms with the highest prevalence, there were: 1) moderate correlations among symptom severity at two and four months post-ICU discharge; and 2) no difference in prevalence or severity by patients' disposition (home vs. institution), except worse fatigue in patients at home at two weeks or less post-ICU discharge. Patients' overall symptom burden showed significant correlation with caregivers' depressive symptoms two weeks or less post-ICU discharge. There were trends of moderate correlations between patients' overall symptom burden and caregivers' health risk behaviors and sleep quality at two and four months post-ICU discharge. CONCLUSION: In our sample, sleep disturbance, fatigue, weakness, and pain were the four key symptoms during first four months post-ICU discharge. Future studies focusing on these four symptoms are necessary to promote quality in post-ICU symptom management.

Health risk behaviors in family caregivers during patients' stay in intensive care units: a pilot analysis.

BACKGROUND: Studies of family caregivers of the critically ill have mainly focused on the psychological impact of the patients' stay in the intensive care unit and related stress. Despite known associations between stress and physical health, limited attention has been paid to the need to promote and maintain physical health in these caregivers. OBJECTIVE: To explore how family caregivers' health risk behaviors are associated with patients' preexisting care needs and the caregivers' depressive symptoms and burden. METHODS: During the intensive-care-unit stay of critically ill patients (who required mechanical ventilation for ≥4 days), 50 family caregivers were surveyed to determine the caregivers' depressive symptoms, burden, and health risk behaviors. Data were also collected on patients' care needs before admission to the intensive care unit. RESULTS: One or more health risk behaviors were reported by 94% of family caregivers. More than 90% of caregivers reported depressive symptoms above the score indicating risk for clinical depression. A high level of burden was reported by 36% of caregivers. More health risk behaviors were associated with higher scores of depressive symptoms and burden (P < .001 for both). Caregivers' responses did not differ according to patients' preexisting care needs. CONCLUSION: Health risk behaviors of family caregivers are associated with greater perceptions of burden and/or depressive symptoms but not with patients' care needs before admission to the intensive care unit.

Current venues of care and related costs for the chronically critically ill.

The chronically critically ill (CCI) patient population is characterized by a prolonged need for high cost medical interventions, a high 1-year mortality rate, and a very high demand for post acute care services. The best characterized CCI patient population is patients on prolonged mechanical ventilation (PMV). This review will focus on the current knowledge of costs and care venues for the care of this patient population. The PMV population suffers from a prolonged length of acute care hospital stay, median hospital costs 3-4 times the cost of short-term ventilator patients, frequent care venue changes during the course of illness, a small likelihood of discharge to the home environment, yet a hospital mortality that does not differ significantly from the short-term ventilated patient group. The PMV population is projected to double in size by the year 2020. Given the dramatic comparative acute care cost burden of PMV patients, the societal implications for managing both the care burden and the costs of care are staggering. Strategies to improve the efficiency in healthcare for this patient population will be essential. Limitations to the existing care models in the United States will be identified with a focus on our current research deficiencies, which limit healthcare providers and administrators in providing patient focused care for this patient population.

Patterns of depressive symptoms in caregivers of mechanically ventilated critically ill adults from intensive care unit admission to 2 months postintensive care unit discharge: a pilot study.

OBJECTIVE: To examine trajectories of depressive symptoms in caregivers of critically ill adults from intensive care unit admission to 2 months postintensive care unit discharge and explore patient and caregiver characteristics associated with differing trajectories. DESIGN: Longitudinal descriptive study. SETTING: Medical intensive care unit in a tertiary university hospital. SUBJECTS: Fifty caregivers and 47 patients on mechanical ventilation for ≥4 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Caregivers completed measures assessing depressive symptoms (Short version Center for Epidemiologic Studies-Depression Scale 10-items), burden (Brief Zarit Burden Interview), and health risk behaviors (caregiver health behaviors) during intensive care unit admission, at intensive care unit discharge, and 2 months postintensive care unit discharge. Group-based trajectory analysis was used to identify patterns of change in shortened Center for Epidemiologic Studies-Depression Scale scores over time. Two trajectory groups emerged: 1) caregivers who had clinically significant depressive symptoms (21.0±4.1) during intensive care unit admission that remained high (13.6±5) at 2 months postintensive care unit discharge (high trajectory group, 56%); and 2) caregivers who reported scores that were lower (10.6±5.7) during intensive care unit admission and decreased further (5.7±3.6) at 2 months postintensive care unit discharge (low trajectory group, 44%). Caregivers in the high trajectory group tended to be younger, female, an adult child living with financial difficulty, and less likely to report a religious background or preference. More caregivers in the high trajectory group reported greater burden and more health risk behaviors at all time points; patients tended to be male with poorer functional ability at intensive care unit discharge. Caregivers' responses during intensive care unit admission did not differ in regard to number of days patients were on mechanical ventilation before enrollment. CONCLUSION: Findings suggest two patterns of depressive symptom response in caregivers of critically ill adults on mechanical ventilation from intensive care unit admission to 2 months postintensive care unit discharge. Future studies are necessary to confirm these findings and implications for providing caregiver support.

Acute exacerbation of subclinical pulmonary fibrosis after red blood cell transfusion: a case report.

BACKGROUND: Red blood cell (RBC) transfusion is associated with lung injury in susceptible hosts, although many cases do not meet criteria for transfusion-related acute lung injury. Patients with underlying pulmonary fibrosis can exhibit precipitous deteriorations in respiratory status of unknown etiology defined as acute exacerbations due to superimposed lung injury syndrome. It is unclear whether RBC transfusion is associated with acute exacerbation of underlying pulmonary fibrosis. CASE REPORT: We describe a patient who underwent an uneventful elective left total hip replacement but developed anemia postoperatively. Twenty-four hours after transfusion of her fifth nonleukoreduced AS-5 RBC unit, she developed new bilateral airspace infiltrates associated with progressive hypoxemia. These RBC units were 35 to 38 days old. Despite supportive care and diuresis, the patient remained profoundly hypoxemic with infiltrates that progressed to fibrosis. RESULTS: The patient had mild subclinical lower-lobe predominant interstitial pulmonary fibrosis but developed diffuse bilateral ground glass opacities with areas of consolidation 24 hours after receiving her last RBC unit. Transbronchial biopsy of the right lower lobe showed active organizing pneumonia and underlying interstitial fibrosis, supporting the clinical diagnosis of acute exacerbation of pulmonary fibrosis. The bronchoalveolar lavage showed progressive bloody effluent, consistent with diffuse alveolar hemorrhage, a marker of lung injury. There was no evidence of viral inclusions, fungal elements, pneumocystis, or bacterial organisms. CONCLUSION: Transfusion of multiple units of aged RBCs was temporally associated with an acute exacerbation and rapid progression of underlying subclinical pulmonary fibrosis.