Effects Of Critical Illness Research Articles

The impact of critical illness on patients’ physical function and recovery: An explanatory mixed-methods analysis

ObjectivesTo determine how the perception of physical function 6-months following critical illness compares to objectively measured function, and to identify key concerns for patients during recovery from critical illness. Research methodology and designA nested convergent parallel mixed methods study assessed physical function during a home visit 6-months following critical illness, with semi-structured interviews conducted at the same time. SettingParticipants were recruited from two hospitals at one healthcare network in Melbourne, Australia from September 2017 to October 2018 with follow-up data completed in April 2019. Main Outcome MeasuresPhysical function was assessed through four objective outcomes: the functional independence measure, six-minute walk test, functional reach test, and grip strength. Semi structured interviews focused on participants function, memories of the intensive care and hospital stay, assistance required on discharge, ongoing limitations, and the recovery process. FindingsAlthough many participants (12/20, 60%) stated they had recovered from their critical illness, 14 (70%) had function below expected population norms. Decreased function on returning home was commonly reported, although eleven participants were described as independent and safe for discharge from hospital-based staff. The importance of family and social networks to facilitate discharge was highlighted, however participants often described wanting more support and issues accessing services. The effect of critical illness on the financial well-being of the family network was confirmed, with difficulties accessing financial support identified. ConclusionSurvivors of critical illness perceived a better functional state than measured, but many report new limitations 6-months after critical illness. Family and friends play a crucial role in facilitating transition home and providing financial support. Implications for clinical practiceImplementation of specific discharge liaison personnel to provide education, support and assist the transition from hospital-based care to home, particularly in those without stable social supports, may improve the recovery process for survivors of critical illness.

Micronutrient intake to protect against osteoporosis during and after critical illness.

Improved survival from critical illness has enhanced the focus on ways to augment functional outcomes following discharge from the Intensive Care Unit. An area that is gaining increased attention is the effect of critical illness on bone health and fragility fractures following the episode. This review discusses the micronutrients that may play a role in bone metabolism and the potential benefits of their supplementation to prevent osteoporosis. These include calcium, phosphorous, magnesium, vitamin D, vitamin C, vitamin K, and certain trace elements. Although there is sound physiological basis for the involvement of these micronutrients in bone health and fracture prevention, there are few clinically relevant publications in this area with calcium and vitamin D being the best studied to date. In the absence of high-quality evidence in critically ill populations, attention to measurement and supplementation of these micronutrients as per current guidelines outlining micronutrient requirements in enteral and parenteral nutrition might mitigate bone loss and its sequelae in the recovery phase from critical illness.

Recuperação Psicológica após Adoecimento Grave e Internação em UTI

Abstract The effects of critical illness and hospitalization in intensive care units (ICU) have been associated with the presence of negative psychological consequences. This study explores the experiences of sick people who were admitted to an ICU, seeking to know its repercussions on the self. In-depth qualitative interviews and participant observations were carried out with two people since their ICU admission until at least six months after discharge from the unit. Data was analyzed following an adaptation of the clinical qualitative method within a longitudinal frame and interpreted with Winnicott’s psychoanalytic perspective. This research managed to describe participants’ lived experiences and the ways they affected their psychic organization. To the interviewed, these experiences configured threshold situations which promoted a process of psychic disintegration. Psychological recovery, then, depends on the articulation of lived experiences, and is supported by facilitating intersubjective relationships that promote the expression of personal potentialities.

Effects of critical illness on the functional status of children with a history of prematurity

Effects of critical illness on the functional status of children with a history of prematurity

Long-term sequelae of critical illness in sepsis, trauma and burns: A systematic review and meta-analysis.

Sepsis, major trauma, and severe burn injury are life-threatening critical illnesses that remain significant contributors to worldwide morbidity and mortality. The three underlying etiologies share pathophysiological similarities: hyperinflammation, hypermetabolism, and acute immunomodulation. The aims of this study were to assess the current state of long-term outcome research and to identify key outcome parameters between the three forms of critical illness. This systematic review and meta-analysis (MA) were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. PubMed was searched from January 1, 1975, to December 31, 2019. Studies were assessed for eligibility by independent reviewers. Inclusion criteria were studies reporting at least a 6-month follow-up of health-related quality of life and organ-specific sequelae within the three etiologies: severe burn injury, sepsis, and major trauma. In total, 125 articles could be included in the systematic review and 74 in the MA. The mean follow-up time was significantly longer in burn studies, compared with sepsis and trauma studies. The majority of patients were from the sepsis group, followed by burns, and major trauma studies. In the overall health-related quality of life, as assessed by Short Form 36 and European Quality-of-Life Index, the three different etiologies were comparable with one another. The effects of critical illness on survivors persist for years after hospitalization. Well-reported and reliable data on the long-term outcomes are imperative, as they can be used to determine the treatment choice of physicians and to guide the expectations of patients, improving the overall quality of care of three significant patient cohorts. Systematic review and MA, level III.

Metabolism of Proteins and Amino Acids in Critical Illness: From Physiological Alterations to Relevant Clinical Practice.

The clinical impact of nutrition therapy in critically ill patients has been known for years, and relevant guidelines regarding nutrition therapy have emphasized the importance of proteins. During critical illness, such as sepsis or the state following major surgery, major trauma, or major burn injury, patients suffer from a high degree of stress/inflammation, and during this time, metabolism deviates from homeostasis. The increased degradation of endogenous proteins in response to stress hormones is among the most important events in the acute phase of critical illness. Currently published evidence suggests that adequate protein supplementation might improve the clinical outcomes of critically ill patients. The role of sufficient protein supplementation may even surpass that of caloric supplementation. In this review, we focus on relevant physiological alterations in critical illness, the effects of critical illness on protein metabolism, nutrition therapy in clinical practice, and the function of specific amino acids.

Neurological update: COVID-19

Coronavirus Disease 2019 is predominantly a disorder of the respiratory system, but neurological complications have been recognised since early in the pandemic. The major pathophysiological processes leading to neurological damage in COVID-19 are cerebrovascular disease, immunologically mediated neurological disorders and the detrimental effects of critical illness on the nervous system. It is still unclear whether direct invasion of the nervous system by the Severe Acute Respiratory Syndrome Coronavirus 2 occurs; given the vast numbers of people infected at this point, this uncertainty suggests that nervous system infection is unlikely to represent a significant issue if it occurs at all. In this review, we explore what has been learnt about the neurological complications of COVID-19 over the course of the pandemic, and by which mechanisms these complications most commonly occur.

Changes in Respiratory Muscle Thickness during Mechanical Ventilation: Focus on Expiratory Muscles.

The lateral abdominal wall muscles are recruited with active expiration, as may occur with high breathing effort, inspiratory muscle weakness, or pulmonary hyperinflation. The effects of critical illness and mechanical ventilation on these muscles are unknown. This study aimed to assess the reproducibility of expiratory muscle (i.e., lateral abdominal wall muscles and rectus abdominis muscle) ultrasound and the impact of tidal volume on expiratory muscle thickness, to evaluate changes in expiratory muscle thickness during mechanical ventilation, and to compare this to changes in diaphragm thickness. Two raters assessed the interrater and intrarater reproducibility of expiratory muscle ultrasound (n = 30) and the effect of delivered tidal volume on expiratory muscle thickness (n = 10). Changes in the thickness of the expiratory muscles and the diaphragm were assessed in 77 patients with at least two serial ultrasound measurements in the first week of mechanical ventilation. The reproducibility of the measurements was excellent (interrater intraclass correlation coefficient: 0.994 [95% CI, 0.987 to 0.997]; intrarater intraclass correlation coefficient: 0.992 [95% CI, 0.957 to 0.998]). Expiratory muscle thickness decreased by 3.0 ± 1.7% (mean ± SD) with tidal volumes of 481 ± 64 ml (P < 0.001). The thickness of the expiratory muscles remained stable in 51 of 77 (66%), decreased in 17 of 77 (22%), and increased in 9 of 77 (12%) patients. Reduced thickness resulted from loss of muscular tissue, whereas increased thickness mainly resulted from increased interparietal fasciae thickness. Changes in thickness of the expiratory muscles were not associated with changes in the thickness of the diaphragm (R2 = 0.013; P = 0.332). Thickness measurement of the expiratory muscles by ultrasound has excellent reproducibility. Changes in the thickness of the expiratory muscles occurred in 34% of patients and were unrelated to changes in diaphragm thickness. Increased expiratory muscle thickness resulted from increased thickness of the fasciae.

Effects of thiamine on vasopressor requirements in patients with septic shock: a prospective randomized controlled trial

BackgroundThiamine, an essential vitamin for aerobic metabolism and glutathione cycling, may decrease the effects of critical illnesses. The objective of this study was to determine whether intravenous thiamine administration can reduce vasopressor requirements in patients with septic shock.MethodsThis study was a prospective randomized double-blind placebo-controlled trial. We included adult patients with septic shock who required a vasopressor within 1–24 h after admission between March 2018 and January 2019 at a tertiary hospital in Thailand. Patients were divided into two groups: those who received 200 mg thiamine or those receiving a placebo every 12 h for 7 days or until hospital discharge. The primary outcome was the number of vasopressor-free days over 7 days. The pre-defined sample size was 31 patients per group, and the study was terminated early due to difficult recruitment.ResultsSixty-two patients were screened and 50 patients were finally enrolled in the study, 25 in each group. There was no difference in the primary outcome of vasopressor-free days within the 7-day period between the thiamine and placebo groups (mean: 4.9 days (1.9) vs. 4.0 days (2.7), p = 0.197, mean difference − 0.9, 95% CI (− 2.9 to 0.5)). However, the reductions in lactate (p = 0.024) and in the vasopressor dependency index (p = 0.02) at 24 h were greater among subjects who received thiamine repletion vs. the placebo. No statistically significant difference was observed in SOFA scores within 7 days, vasopressor dependency index within 4 days and 7 days, or 28-day mortality.ConclusionsThiamine was not associated to a significant reduction in vasopressor-free days over 7-days in comparison to placebo in patients with septic shock. Administration of thiamine could be associated with a reduction in vasopressor dependency index and lactate level within 24 h. The study is limited by early stopping and low sample size.Trial registrationTCTR, TCTR20180310001. Registered 8 March 2018, http://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&smenu=fulltext&task=search&task2=view1&id=3330.

Circadian Gene Expression Rhythms During Critical Illness.

Core clock genes regulate tissue-specific transcriptome oscillations that synchronize physiologic processes throughout the body, held in phase by the central circadian rhythm. The central circadian rhythm rapidly dampens with onset of critical illness, but the effect of critical illness on gene expression oscillations is unknown. The objective of this study was to characterize the rhythmicity and phase coherence of core clock genes and the broader transcriptome after onset of critical illness. Cross-sectional study. ICUs and hospital clinical research unit. Critically ill patients within the first day of presenting from the community and healthy volunteers. Usual care (critically ill patients) and modified constant routine (healthy volunteers). We studied 15 critically ill patients, including 10 with sepsis and five with intracerebral hemorrhage, and 11 healthy controls. The central circadian rhythm and rest-activity rhythms were profiled by continuous wrist actigraphy, and serum melatonin sampled every 2 hours along with whole blood for RNA isolation over 24 hours. The gene expression transcriptome was obtained by RNA sequencing. Core clock genes were analyzed for rhythmicity by cosinor fit. Significant circadian rhythmicity was identified in five of six core clock genes in healthy controls, but none in critically ill patients. TimeSignature, a validated algorithm based on 41 genes, was applied to assess overall transcriptome phase coherence. Median absolute error of TimeSignature was higher in individual critically ill patients than healthy patients (4.90 vs 1.48 hr) and was correlated with encephalopathy severity by Glasgow Coma Scale in critically ill patients (rho, -0.54; p = 0.036). Gene expression rhythms rapidly become abnormal during critical illness. The association between disrupted transcriptome rhythms and encephalopathy suggests a path for future work to elucidate the underlying pathophysiology.

The impact of critical illness on the expiratory muscles and the diaphragm assessed by ultrasound in mechanical ventilated children

BackgroundCritical illness has detrimental effects on the diaphragm, but the impact of critical illness on other major muscles of the respiratory pump has been largely neglected. This study aimed to determine the impact of critical illness on the most important muscles of the respiratory muscle pump, especially on the expiratory muscles in children during mechanical ventilation. In addition, the correlation between changes in thickness of the expiratory muscles and the diaphragm was assessed.MethodsThis longitudinal observational cohort study performed at a tertiary pediatric intensive care unit included 34 mechanical ventilated children (> 1 month– < 18 years). Thickness of the diaphragm and expiratory muscles (obliquus interna, obliquus externa, transversus abdominis and rectus abdominis) was assessed daily using ultrasound. Contractile activity was estimated from muscle thickening fraction during the respiratory cycle.ResultsOver the first 4 days, both diaphragm and expiratory muscles thickness decreased (> 10%) in 44% of the children. Diaphragm and expiratory muscle thickness increased (> 10%) in 26% and 20% of the children, respectively. No correlation was found between contractile activity of the muscles and the development of atrophy. Furthermore, no correlation was found between changes in thickness of the diaphragm and the expiratory muscles (P = 0.537). Decrease in expiratory muscle thickness was significantly higher in patients failing extubation compared to successful extubation (− 34% vs − 4%, P = 0.014).ConclusionsChanges in diaphragm and expiratory muscles thickness develop rapidly after the initiation of mechanical ventilation. Changes in thickness of the diaphragm and expiratory muscles were not significantly correlated. These data provide a unique insight in the effects of critical illness on the respiratory muscle pump in children.

Persistence of patient and family experiences of critical illness

ObjectiveTo investigate: (1) patient and family experiences with healthcare and the intensive care unit (ICU); (2) experiences during their critical illness; (3) communication and decision making during critical illness; (4)...

Nutrition and the gut microbiome during critical illness: A new insight of nutritional therapy.

Changes in the microbiome in response to environmental influences can affect the overall health. Critical illness is considered one of the major environmental factors that can potentially influence the normal gut homeostasis. It is associated with pathophysiological effects causing damage to the intestinal microbiome. Alteration of intestinal microbial composition during critical illness may subsequently compromise the integrity of the intestinal epithelial barrier and intestinal mucosa absorptive function. Many factors can impact the microbiome of critically ill patients including ischemia, hypoxia and hypotension along with the iatrogenic effects of therapeutic agents and the lack of enteral feeds. Factors related to disease state and medication are inevitable and they are part of the intensive care unit (ICU) exposure. However, a nutritional intervention targeting gut microbiota might have the potential to improve clinical outcomes in the critically ill population given the extensive vascular and lymphatic links between the intestines and other organs. Although nutrition is considered an integral part of the treatment plan of critically ill patients, still the role of nutritional intervention is restricted to improve nitrogen balance. What is dismissed is whether the nutrients we provide are adequate and how they are processed and utilised by the host and the microbiota. Therefore, the goal of nutrition therapy during critical illness should be extended to provide good quality feeds with balanced macronutrient content to feed up the entire body including the microbiota and host cells. The main aim of this review is to examine the current literature on the effect of critical illness on the gut microbiome and to highlight the role of nutrition as a factor affecting the intestinal microbiome-host relationship during critical illness.

Progressive mobility program and technology to increase the level of physical activity and its benefits in respiratory, muscular system, and functionality of ICU patients: study protocol for a randomized controlled trial

BackgroundEnhanced mobility in the Intensive Care Unit (ICU) could minimize the negative effects of critical illness, such as declines in cognitive, muscular, respiratory, and functional capacity. We aim to compare the functional status at ICU discharge of patients who underwent a progressive mobilization protocol versus patients who received conventional physiotherapy. We also examine the level of physical activity in the ICU, the degree of pulmonary and muscle function, and the length of stay to analyze correlations between these variables.MethodsThis is a protocol for a randomized controlled trial with blind evaluation. Ninety-six ICU patients will be recruited from a single center and randomly assigned to a control group or an intervention group. To determine the level of protocol activity the patient will receive, the patients’ ability to participate actively and their muscle strength will be considered. The protocol consists of five phases, ranging from passive therapies to walking and climbing stairs. The primary outcome will be the functional status at ICU discharge, measured with the Barthel Index and the ICU Mobility Scale (IMS). Measured secondary outcomes will include the level of physical activity, maximal inspiratory and expiratory pressures, forced expiratory volume in 1 second, maximum voluntary ventilation, handgrip strength, surface electromyography of the lower limb muscles, and results of the Timed Up and Go and 2-Minute Walk tests. Evaluations will be made within 2 days of ICU discharge except for the level of activity, which will be evaluated daily. Physiological variables and activity level will be analyzed by chi-square and t tests, according to the intention-to-treat paradigm.DiscussionMobility and exercise in the ICU should be undertaken with intensity, quantity, duration, and frequency adjusted according to the patients’ status. The results of this study may contribute to new knowledge of early mobility in the ICU, activity level, and varying benefits in critical patients, directing new approaches to physiotherapeutic interventions in these patients.Trial registrationRecruitment will begin in February 2017, and the expected completion date is August 2018. Patients are already being recruited.ClinicalTrials.gov, ID: NCT02889146. Registered on 3 March 2016.

Parenteral or Enteral Arginine Supplementation Safety and Efficacy

Arginine supplementation has the potential to improve the health of patients. Its use in hospitalized patients has been a controversial topic in the nutrition literature, especially concerning supplementation of septic patients. In this article, we review the relevant literature both for and against the use of arginine in critically ill, surgical, and hospitalized patients. The effect of critical illness on arginine metabolism is reviewed, as is its use in septic and critically ill patients. Although mounting evidence supports immunonutrition, there are only a few studies that suggest that this is safe in patients with severe sepsis. The use of arginine has been shown to benefit a variety of critically ill patients. It should be considered for inclusion in combinations of immunonutrients or commercial formulations for groups in whom its benefit has been reported consistently, such as those who have suffered trauma and those in acute surgical settings. The aims of this review are to discuss the role of arginine in health, the controversy surrounding arginine supplementation of septic patients, and the use of arginine in critically ill patients.

Improving survivorship after critical illness

As medical treatments and technology advance, increasing numbers of patients are surviving more severe forms of critical illness. The negative medical, physical, psychological and social effects of critical illness and its treatment are often long lasting and not limited to the time the patient spends on the intensive care unit. The primary care management of this complex patient group is as important as the initial resuscitation and treatment in hospital. Carefully coordinated, multi-disciplinary team treatment and rehabilitation is required in order to reduce the morbidity of survivors and their carers.

중증질환으로 인한 소득상실리스크와 정책적 시사점

중증질환으로 인한 소득상실리스크와 정책적 시사점

The effect of critical illness on the pharmacokinetics and dose-response relationship of midazolam

The effect of critical illness on the pharmacokinetics and dose-response relationship of midazolam

Aberrant bone metabolism in critical illness

Critically ill patients present with distinct alterations in bone metabolism. We have previously reported a decrease in bone formation markers and a dramatic increase in bone resorption markers. In a rabbit model of critical illness, we observed significantly lower bone mineral content in the trabeculae of critically ill rabbits compared to healthy controls. This suggested uncoupling between bone formation and degradation during critical illness, and could increase risk of fracture during rehabilitation or impaired healing of bone fractures. In this study, we investigated the effect of critical illness on bone metabolism at the tissue and cellular level.

Effect of critical illness on the pharmacokinetics and dose-response relationship of midazolam

Critically ill patients require sedation to tolerate the interventions necessary to facilitate their care. There is growing evidence, however, that use of sedatives, such as the benzodiazepine midazolam, is associated with delirium and other complications that can lead to prolonged ICU stay and increased mortality. The pharmacokinetics of midazolam in healthy populations has been well characterized, and pharmacodynamic studies demonstrate a predictable dose-response relationship. However, in critical illness, where midazolam is often administered as a continuous infusion, the pharmacokinetic properties are often altered. We sought to investigate whether analysis of midazolam plasma concentrations in combination with electroencephalography (EEG) will better define the effect of critical illness on the pharmacokinetics and clinical response to midazolam, while providing a method to assess the adequacy of sedation thereby minimizing the risks associated with prolonged or over-sedation.