Return to work after critical illness: a systematic review and meta-analysis.

BACKGROUND: Survivors of critical illness often experience poor outcomes after hospitalisation, including delayed return to work, which carries substantial economic consequences. OBJECTIVE: To conduct a systematic review and meta-analysis of return to work after critical illness. METHODS: We searched PubMed, Embase, PsycINFO, CINAHL and Cochrane Library from 1970 to February 2018. Data were extracted, in duplicate, and random-effects meta-regression used to obtain pooled estimates. RESULTS: Fifty-two studies evaluated return to work in 10 015 previously employed survivors of critical illness, over a median (IQR) follow-up of 12 (6.25-38.5) months. By 1-3, 12 and 42-60 months' follow-up, pooled return to work prevalence (95% CI) was 36% (23% to 49%), 60% (50% to 69%) and 68% (51% to 85%), respectively (τ2=0.55, I2=87%, p=0.03). No significant difference was observed based on diagnosis (acute respiratory distress syndrome (ARDS) vs non-ARDS) or region (Europe vs North America vs Australia/New Zealand), but was observed when comparing mode of employment evaluation (in-person vs telephone vs mail). Following return to work, 20%-36% of survivors experienced job loss, 17%-66% occupation change and 5%-84% worsening employment status (eg, fewer work hours). Potential risk factors for delayed return to work include pre-existing comorbidities and post-hospital impairments (eg, mental health). CONCLUSION: Approximately two-thirds, two-fifths and one-third of previously employed intensive care unit survivors are jobless up to 3, 12 and 60 months following hospital discharge. Survivors returning to work often experience job loss, occupation change or worse employment status. Interventions should be designed and evaluated to reduce the burden of this common and important problem for survivors of critical illness. TRIAL REGISTRATION NUMBER: PROSPERO CRD42018093135.

Psychological Sequelae in Family Caregivers of Critically III Intensive Care Unit Patients. A Systematic Review.

Rationale: Family members of critically ill patients hospitalized in the intensive care unit (ICU) often become caregivers, and they are at risk to develop adverse psychological outcomes. There is a need to understand the psychological impact of critical illness on family caregivers. Objectives: The aim of this systematic review is to document the prevalence of depression, anxiety, and post-traumatic stress disorder (PTSD) in family caregivers of critically ill patients and identify potential risk factors for psychological outcomes to inform clinical and future research recommendations. Methods: A literature search for psychological outcomes for family caregivers of critically ill patients was conducted. A total of 1,148 studies from PsycINFO, CINAHL, Web of Science, SCOPUS, and Medline were identified. Results: Forty studies met inclusion criteria and were included in the review. The prevalence of psychological outcomes in family caregivers ranged from 4% to 94% for depression, 2% to 80% for anxiety, and 3% to 62% for PTSD. Caregiver depression, anxiety, and PTSD decreased in most studies that assessed longitudinal outcomes. Common risk factors identified for adverse psychological outcomes included younger caregiver age, caregiver relationship to the patient, lower socioeconomic status, and female sex. Conclusions: The prevalence of depression, anxiety, and PTSD varies greatly across studies of family caregivers of critically ill patients. This finding highlights the need for more systematic investigations of psychological outcomes and the implementation of clinical interventions to prevent or reduce depression, anxiety, and PTSD in family caregivers of critically ill patients.

Instrumental Activities of Daily Living after Critical Illness: A Systematic Review.

RATIONALE: Poor functional status is common after critical illness, and can adversely impact the abilities of intensive care unit (ICU) survivors to live independently. Instrumental activities of daily living (IADL), which encompass complex tasks necessary for independent living, are a particularly important component of post-ICU functional outcome. OBJECTIVES: To conduct a systematic review of studies evaluating IADLs in survivors of critical illness. METHODS: We searched PubMed, CINAHL, Cochrane Library, SCOPUS, and Web of Science for all relevant English-language studies published through December 31, 2016. Additional articles were identified from personal files and reference lists of eligible studies. Two trained researchers independently reviewed titles and abstracts, and potentially eligible full text studies. Eligible studies included those enrolling adult ICU survivors with IADL assessments, using a validated instrument. We excluded studies involving specific ICU patient populations, specialty ICUs, those enrolling fewer than 10 patients, and those that were not peer-reviewed. Variables related to IADLs were reported using the Patient Reported Outcomes Measurement Information System (PROMIS). RESULTS: Thirty of 991 articles from our literature search met inclusion criteria, and 23 additional articles were identified from review of reference lists and personal files. Sixteen studies (30%) published between 1999 and 2016 met eligibility criteria and were included in the review. Study definitions of impairment in IADLs were highly variable, as were reported rates of pre-ICU IADL dependencies (7-85% of patients). Eleven studies (69%) found that survivors of critical illness had new or worsening IADL dependencies. In three of four longitudinal studies, survivors with IADL dependencies decreased over the follow-up period. Across multiple studies, no risk factors were consistently associated with IADL dependency. CONCLUSIONS: Survivors of critical illness commonly experience new or worsening IADL dependency that may improve over time. As part of ongoing efforts to understand and improve functional status in ICU survivors, future research must focus on risk factors for IADL dependencies and interventions to improve these cognitive and physical dependencies after critical illness.

Critical illness acquired brain injury: Neuroimaging and implications for rehabilitation.

OBJECTIVE: The increasing likelihood of surviving critical illness has resulted in a large and growing number of individuals transitioning from medical and surgical intensive care units (ICUs) to their homes. Many ICU survivors develop pervasive morbidities in physical, psychological, and cognitive functioning that adversely impact day-to-day functioning, ability to return to work, and quality-of-life. These individuals have been extensively studied with neuropsychological test batteries, but relatively little research has been conducted using neuroimaging. This paper reviews neuroimaging findings in survivors of critical illness treated in medical or surgical ICUs. METHODS: We assessed the relationships between abnormalities on neuroimaging and cognitive outcomes and discussed the implications for rehabilitation. RESULTS: There are limited imaging studies in ICU survivors. These studies use a wide range of modalities including magnetic resonance imaging (MRI), functional magnetic resonance imaging (fMRI), diffusion tensor imaging (DTI), fluid attenuated inversion recovery (FLAIR), and diffusion weighted imaging. Structural abnormalities in survivors of critical illness include cortical and subcortical lesions, white matter hyperintensities (WMHs), and generalized and focal atrophy. These abnormalities persist months to years after ICU discharge and are associated with cognitive impairments. (PsycINFO Database Record

Improving post-intensive care unit neuropsychiatric outcomes: understanding cognitive effects of physical activity.

Critical illness and its treatment often result in long-term neuropsychiatric morbidities. Consequently, there is a need to focus on means to prevent or ameliorate these morbidities. Animal models provide important data regarding the neurobiological effects of physical activity, including angiogenesis, neurogenesis, and release of neurotrophic factors that enhance plasticity. Studies in noncritically ill patients demonstrate that exercise is associated with increased cerebral blood flow, neurogenesis, and brain volume, which are associated with improved cognition. Clinically, research in both healthy and diseased human subjects suggests that exercise improves neuropsychiatric outcomes. In the critical care setting, early physical rehabilitation and mobilization are safe and feasible, with demonstrated improvements in physical functional outcomes. Such activity may also reduce the duration of delirium in the intensive care unit (ICU) and improve neuropsychiatric outcomes, although data are limited. Barriers exist regarding implementing ICU rehabilitation in routine care, including use of sedatives and lack of awareness of post-ICU cognitive impairments. Further research is necessary to determine whether prior animal and human research, in conjunction with preliminary results from existing ICU studies, can translate into improvements for neuropsychiatric outcomes in critically ill patients. Studies are needed to evaluate biological mechanisms, risk factors, the role of pre-ICU functional level, and the timing, duration, and type of physical activity for optimal patient outcomes.

Blood glucose dysregulation and cognitive outcome in ARDS survivors.

OBJECTIVE: Hyperglycaemia is common in critically ill patients and may contribute to increased mortality and morbidity. This study assessed the impact of blood glucose on cognitive outcome in acute respiratory distress syndrome (ARDS) patients' 1 year post-hospital discharge. DESIGN: Retrospective data for 74 ARDS survivors who were enrolled in a prospective mechanical ventilation randomized clinical trial. A standard protocol was used to manage blood glucose. The highest, lowest, mean and standard deviation glucose values were examined, as well as duration of hypoxemia and other clinical data. Standardized neuropsychological tests were administered to identify cognitive sequelae. Logistic regression models were used to assess risk factors for cognitive sequelae. MEASUREMENTS AND RESULTS: There was a significant relationship between the blood glucose and cognitive sequelae. Greater duration of mechanical ventilation and highest blood glucose predicted cognitive sequelae. CONCLUSIONS: Blood glucose dysregulation, specifically moderate hyperglycaemia and ICU length of stay, predicted adverse cognitive sequelae in ARDS patients.

Neurologic changes during critical illness: brain imaging findings and neurobehavioral outcomes.

Encephalopathy and other neurologic morbidities are common in critical illness, sepsis, and prolonged mechanical ventilation. We assessed structural changes on brain imaging and neuropsychological outcomes in critically ill patients who developed neurological changes during their intensive care unit (ICU) stay. Patients who underwent brain imaging for neurological changes were included in the study. Medical, neuroradiological, and outcome data were obtained from patient medical records. Sixty-four patients underwent brain imaging for neurological changes. Forty-one (64%) patients had abnormalities on brain imaging. There were no differences for age, hospital length of stay, ICU length of stay, duration of mechanical ventilation or APACHE II scores for patients with normal compared to abnormal brain imaging. Cognitive impairments occurred in 48% of survivors and 6% developed psychiatric disorders. Our study demonstrates that abnormalities on brain imaging are common in critically ill patients. We also confirm previous findings that survivors of critical illness have cognitive impairments post-ICU discharge. This study further illustrates the adverse effects of critical illness on the brain and highlights the need for additional research in this emerging area.

Risk factors for depression and anxiety in survivors of acute respiratory distress syndrome.

OBJECTIVE: Depression and anxiety are common morbidities of critical illness. We assessed risk factors of depression and anxiety in Acute Respiratory Distress Syndrome (ARDS) survivors at 1 and 2 years post-hospital discharge. METHOD: Risk factors for depression and anxiety at 1 and 2 years were assessed using stepwise multiple regression analyses, with and without 1-year outcomes. RESULTS: ARDS survivors had depression (16% and 23%) and anxiety (24% and 23%) at 1 and 2 years, respectively. Predictors of depression at 1 year were alcohol dependence, female gender and younger age (P=.006). Predictors of anxiety were ratio of arterial oxygen tension to inspired oxygen fraction and duration of mechanical ventilation (P<.005). Predictors of depression at 2 years were depression at 1 year and the presence of cognitive sequelae (P<.0001). Predictors of anxiety at 2 years was anxiety at 1 year (P<.0001). CONCLUSIONS: Medical variables that predicted depression or anxiety at 1 year no longer predicted depression and anxiety at 2 years. Medical variables appear to have a short-term effect on psychiatric outcomes. At 2 years lifestyle behaviors including history of smoking along with cognitive sequelae, depression and anxiety at 1 year predict depression and anxiety.

Substance dependence and psychiatric disorders are related to outcomes in a mixed ICU population.

OBJECTIVE: Substance dependence disorders are common in hospitalized patients and are associated with poor recovery. We compared mortality and discharge disposition in critically ill patients with and without substance dependence and patients with and without psychiatric disorders. We also compared the prevalence of substance dependence and psychiatric disorders to population data. METHODS: All medical records of shock trauma intensive care unit (ICU) patients (mixed medical and surgical) at LDS Hospital were reviewed for pre-critical illness alcohol dependence, drug dependence, and psychiatric disorders. RESULTS: There were 742 critically ill patients of whom 54% were male, acute respiratory distress syndrome developed in 5.5% and hospital mortality was 21%. The mean acute physiology and chronic health evaluation II scores were 16.5 +/- 7.9, sequential organ failure assessment scores were 6.7 +/- 4.2, duration of mechanical ventilation was 5 +/- 6.2 days, ICU length of stay (LOS) was 7.3 +/- 10.1 days, hospital LOS was 12.3 +/- 12.9 days. Multivariable regression analyses found psychiatric disorders predicted higher hospital mortality (Odds ratio = 1.50), but was not statistically significant (p = 0.08); substance dependence predicted shorter hospital LOS (R ( 2 ) = 0.08, p = 0.01) after controlling for covariates. There was a higher prevalence of substance dependence compared to Utah (p < 0.001) and US population data (p < 0.001). The prevalence of psychiatric disorders was significantly lower in our patients compared to US population data (19 vs. 26%, p < 0.001). CONCLUSIONS: Our data suggest that substance dependence increases hospital LOS and that patients with drug or alcohol dependence are at higher risk for ICU admission compared to the general population.

The changing face of organ failure in ARDS.

OBJECTIVE: To study morbidity and mortality in ARDS patients from 1987 to 1999. DESIGN: Review of a prospectively collected database of ARDS patients. SETTING: Large, community hospital located in Salt Lake City, UT. PATIENTS: ARDS patients identified for the years 1987 to 1999. We prospectively identified ARDS patients at LDS Hospital in Salt Lake City, UT, using PaO(2)/fraction of inspired oxygen ratio (P/F) criteria, the presence of bilateral chest radiograph infiltrates, and the absence of left atrial hypertension. MEASUREMENTS: We assigned a primary risk factor for ARDS and identified the presence of organ failure before and after ARDS. We compared two temporal groups (ie, 1987 to 1990 vs 1994 to 1999) and used two criteria of arterial hypoxemia (P/F: patients from 1994 to 1999, < or = 105 and < or = 173; patients from 1987 to 1990, < or = 0.2) At 1,500 m (the altitude of Salt Lake City), a PaO(2) of < or = 173 corresponds to an alveolar-arterial oxygen pressure difference of < or = 200 at sea level. We used death at hospital discharge as an end point. MAIN RESULTS: We identified 516 ARDS patients with a P/F of < or = 105 (1987 to 1990, 256 patients; 1994 to 1999, 260 patients). Patients who had ARDS between 1994 and 1999 with a P/F of < or = 105 had a lower mortality rate than patients between 1987 and 1990 with a P/F of < or = 105 (44% vs 54%, respectively; p <.05). There were 288 patients with a P/F range of 106 to 173 during 1994 to 1999. Patients from 1994 to 1999 with a P/F of < or = 173 had a lower mortality rate compared to patients from 1987 to 1990 (35% vs 54%, respectively; p <.01). Patients from 1994 to 1999 (for both P/F groups) had statistically fewer total nonpulmonary organ failures (ie, more patients had zero organ failures or single organ failures) and fewer specific organ failures (ie, sepsis, cardiovascular failures, and CNS failures). There were statistically fewer cases of cardiovascular failure, sepsis, and in both periods (ie, prior to ARDS and after the onset of ARDS) for 1994-to-1999 patients with a P/F of < or = 105 compared to 1987-to-1990 patients with a P/F of < or = 105. CONCLUSIONS: Mortality from ARDS has decreased and is associated with decreased organ failure prior to and during the course of ARDS.