Long-stay Intensive Care Unit Patients Research Articles

Long-stay ICU patients with frailty: mortality and recovery outcomes at 6 months

BackgroundProlonged intensive care unit (ICU) stay is associated with physical, cognitive, and psychological disabilities. The impact of baseline frailty on long-stay ICU patients remains uncertain. This study aims to investigate how baseline frailty influences mortality and post-ICU disability 6 months after critical illness in long-stay ICU patients.MethodsIn this retrospective cohort study, we assessed patients hospitalized for ≥ 7 days in the ICU between May 2018 and May 2021, following them for up to 6 months or until death. Based on the Clinical Frailty Scale (CFS) at ICU admissions, patients were categorized as frail (CFS ≥ 5), pre-frail (CFS 3–4) and non-frail (CFS 1–2). Kaplan–Meier curves and a multivariate Cox model were used to examine the association between frailty and mortality. At the 6 month follow-up, we assessed psychological, physical, cognitive outcomes, and health-related quality of life (QoL) using descriptive statistics and linear regressions.ResultsWe enrolled 531 patients, of which 178 (33.6%) were frail, 200 (37.6%) pre-frail and 153 (28.8%) non-frail. Frail patients were older, had more comorbidities, and greater disease severity at ICU admission. At 6 months, frail patients presented higher mortality rates than pre-frail and non-frail patients (34.3% (61/178) vs. 21% (42/200) vs. 13.1% (20/153) respectively, p < 0.01). The rate of withdrawing or withholding of care did not differ significantly between the groups. Compared with CFS 1–2, the adjusted hazard ratios of death at 6 months were 1.7 (95% CI 0.9–2.9) for CFS 3–4 and 2.9 (95% CI 1.7–4.9) for CFS ≥ 5. At 6 months, 192 patients were seen at a follow-up consultation. In multivariate linear regressions, CFS ≥ 5 was associated with poorer physical health-related QoL, but not with poorer mental health-related QoL, compared with CFS 1–2.ConclusionFrailty is associated with increased mortality and poorer physical health-related QoL in long-stay ICU patients at 6 months. The admission CFS can help inform patients and families about the complexities of survivorship during a prolonged ICU stay.

Slow and Steady: Optimizing Intensive Care Unit Treatment Weans for Children with Chronic Critical Illness

AbstractPediatric chronic critical illness (PCCI) is characterized by prolonged and recurrent hospitalizations, multiorgan conditions, and use of medical technology. Our prior work explored the mismatch between intensive care unit (ICU) acute care models and the chronic needs of patients with PCCI. The objective of this study was to examine whether the number and frequency of treatment weans in ICU care were associated with clinical setbacks and/or length of stay for patients with PCCI. A retrospective chart review of the electronic medical record for 300 pediatric patients with PCCI was performed at the neonatal intensive care unit, pediatric intensive care unit, and cardiac intensive care unit of two urban children's hospitals. Daily patient care data related to weans and setbacks were collected for each ICU day. Data were analyzed using multilevel mixed multiple logistic regression analysis and a multilevel mixed Poisson regression. The patient-week level adjusted regression analysis revealed a strong correlation between weans and setbacks: three or more weekly weans yielded an odds ratio of 3.35 (95% confidence interval [CI] = 2.06–5.44) of having one or more weekly setback. There was also a correlation between weans and length of stay, three or more weekly weans were associated with an incidence rate ratio of 1.09 (95% CI = 1.06–1.12). Long-stay pediatric ICU patients had more clinical setbacks and longer hospitalizations if they had more than two treatment weans per week. This suggests that patients with PCCI may benefit from a slower pace of care than is traditionally used in the ICU. Future research to explore the causative nature of the correlation is needed to improve the care of such challenging patients.

Long-stay medical-surgical intensive care unit patients in South Africa: Quality of life and mortality 1 year after discharge

Background. Although mortality is the primary measure of critical care outcome, the health-related quality of life (HRQOL) of survivors is often diminished. There is a paucity of South African research on HRQOL in intensive care unit (ICU) survivors. Objectives. To evaluate the 1-year post-discharge data of long-stay ICU patients, a group known to consume 20 - 40% of ICU resources. Methods. A 1-year prospective observational study was conducted in a multidisciplinary medical-surgical ICU. Adult patients who were mechanically ventilated beyond 6 days were included. Clinical and mortality data were collected. Pre-admission and 6- and 12-month HRQOL were measured with the Short Form-36 questionnaire. Physical and mental component summary scores (PCS and MCS) were calculated. Associations between 12-month mortality and poor HRQOL scores were determined. Results. Of 119 patients enrolled, 40.3% had sustained trauma, 19.3% were post-surgical and 40.3% had medical conditions; 29.2% were HIV-positive (HIV status was known for 74.8% of the cohort). The hospital and 12-month mortality rates were 42.9% and 57.4% (n=66/115), respectively. Age, longer ICU stay, higher disease severity scores and vasopressor use were associated with 12-month mortality. The survivors’ median PCS and MCS at 6 and 12 months were significantly lower compared with pre-admission scores (both p&lt;0.001). At 12 months, 53.1% of survivors demonstrated a poor PCS and 42.9% a poor MCS. Associations with poor 12-month PCS included longer ICU stay, male gender and trauma, while trauma and sepsis were associated with a poor 12-month MCS. Among the 19 trauma survivors, 78.9% had a poor MCS and/or PCS. Of previously employed patients, 54.8% were unemployed at 12 months. Conclusions. Patients ventilated beyond 6 days in a multidisciplinary ICU had a high mortality. Poor HRQOL at 12 months post discharge was frequently observed among survivors. Trauma was associated with poor 12-month outcomes. These findings highlight the need to further explore the outcomes of long-stay ICU patients in Africa.

Impact of introducing a maternity observation and response chart

s / Australian Critical Care 27 (2014) 43–63 57 Impact of introducing a maternity observation and response chart A. Doric ∗, V. Watkins Eastern Health, Australia Introduction: Pregnancy and childbearing is generally a normal life event for a healthy woman. Serious illness in pregnancy and childbearing can be insidious in onset and difficult to recognise due to the compensatory mechanisms of pregnancy. Objectives: In order to improve recognition of deterioration for childbearing women, a maternity observation and response chart was developed using the current evidence base and experience from case studies. Methods: Cases of clinical deterioration in childbearing women in our health network were analysed using audit of WHOMaternal Near Miss (MNM) criteria over the preceding 24 months. A review of existing maternity observation charts revealed linear recording of vital signs with no space to record respiratory rate or fundal height. Observation and escalation criteria for childbearing women were revised to detect early deterioration and then incorporated into observation charts. Following education and clinical support for maternity staff, the observation charts and obstetric escalation criteria were introduced in November 2011. Results: Haemorrhage (66%) and sepsis (21%) were identified as the most common conditions leading to serious clinical deterioration meeting MNM criteria of childbearing women in our health service. Early warning signs of impending deterioration most frequently included respiratory dysfunction, increasinguterine fundal height, heavy postnatal lochia, pain, and ‘looks unwell’. These signs often appeared prior to deterioration in blood pressure or heart rate. The maternity observation charts and escalation criteria have been in use for over 18 months. To date we have seen an increased rate of systematic observation and documentation of the vital signs and clinical status of childbearing women post birth. The charts have also supported clinicians’ decision making and empowered midwives to escalate care when required. In addition, these charts are anobjective tool to assist in the identificationof barriers to early recognition and response to clinical deterioration, so thatmeasures can be adopted to address these issues at an organisational level. Conclusions:The introduction of thematernity observation and response chart and associated escalation criteria are contributing to early and improved recognition and response to clinical deterioration in childbearing women across our health network. http://dx.doi.org/10.1016/j.aucc.2013.10.044 Tissue adhesive—A novel approach to the securement of intra-arterial catheters? A randomised controlled pilot study M. Edwards1,∗, C. Rickard1,2, I. Rapchuk1, A. Corley1,2, N. Marsh2, A. Spooner1,2, G. Mihala2, J. Fraser1,2 1 Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Queensland, Australia 2 Intravascular Access Device Research Group, NHMRC Centre for Research Excellence in Nursing Interventions for Hospitalised Patients, Griffith Health Institute, Queensland, Australia Critically ill patients typically require peripheral intra-arterial catheters (IALs), yet current catheter securement methods are not always adequate—leading to catheter failure and repeated insertions. This study aimed to identify the best securement method to prevent IAL failure. A randomised, controlled, non-blindedpilot trialwas conducted at a tertiary hospital. After informed consent, 217 patients were randomised to: (i) tissue adhesive (TA), (ii) bordered polyurethane (BPU), (iii) sutureless securement device (SSD), or (iv) control. All groups received standard polyurethane dressing (SPU). In controls, SPU was the only product used. The primary endpoint was IAL failure defined as any of: dislodgement (complete), occlusion (monitor failure, cannot infuse, or fluid leakingwhen infused), pain, or infection (local or bloodstream infection). The median IAL dwell time was 26h (IQR: 23–45). Catheter failure was not statistically different between groups (p=0.12), occurring at rates of 1.2 (SPU), 1.3 (BPU, p=0.94), 4.7 (SSD, p=0.08), and 2.8 (TA, p=0.50) per 1000 catheter hours. The SPU control dressing was problematic with clinical staff holding serious concerns about the safety of these dressings in eight patients resulting in their early study completion (censoring). There were no infections in any group. SPU dressings used alone are problematic. The addition of new product classes such as BPU or SSD, or the novel approach of TA could improve outcomes for patients with IALs. Further research is now underway to test these approaches in a large multi-site study. http://dx.doi.org/10.1016/j.aucc.2013.10.046 Development of a multi-disciplinary communication tool (MdCT) for long stay patients in the intensive care unit (ICU) D. Housiaux1,∗, T. Bucknall 1,2, C. Bell 1, K.J. Farley1, J. Sheldrake1 1 Alfred Hospital, Australia 2 Deakin University, Australia Introduction: Evidence reveals that 2.3% of ICU patients have a length of stay (LOS) greater than 21 days, representing 23% of ICU bed hour usage. These long-stay ICU patients have significant physical and psychological needs that require a co-ordinated approach from a multi-disciplinary team. Objectives: 1) Analyse the literature to identify factors influencing long term patient management. 2) Identify tools that improve communication, patient management and patient outcomes. 3) Develop a MdCT relevant to Australian ICUs.

Neglect of quality-of-life considerations in intensive care unit family meetings for long-stay intensive care unit patients*

To examine the frequency with which quality of life and treatment limitation were discussed in formal family meetings for long-stay intensive care unit patients with high risk for mortality and morbidity. Descriptive observational study. Five intensive care units. One hundred sixteen family surrogate decisionmakers of long-stay intensive care unit patients who participated in an intensive communication system that aimed to provide weekly meetings with family decisionmakers. The structure of each meeting was to address medical update, patient preferences, treatment plan, and milestones for evaluating the treatment plan. None. We audiotaped initial family meetings for 116 family decisionmakers for a total of 180 meetings. On average, meetings were 24 mins long with a majority of time being devoted to nonemotional speech and little (12%) spent discussing patient preferences. Quality of life was discussed in 45% and treatment limitation in 23% of all meetings. Quality-of-life discussions were more likely to occur when patients were admitted to a medical intensive care unit (odds ratio [OR] 5.9; p = .005), have a family decisionmaker who is a spouse (OR 9.4; p = .0001), were older (OR 1.04; p = 01), have a shorter length of stay (OR 0.93; p = .001), and have a family decisionmaker who was a spouse (OR 5.1; p = .002). For those with a treatment limitation discussion, 67% had a do-not-resuscitate order, 40% were admitted to a medical intensive care unit, 56% had a family decisionmaker who had been their caregiver, and 48% of their family decisionmakers were their children. To guide discussion with families of the subset of intensive care unit patients with high risk of mortality and long-term morbidity, quality of life was not consistently addressed. Continued efforts to assist clinicians in routinely including discussions of quality-of-life outcomes is needed.

Neglect of quality-of-life considerations in intensive care unit family meetings for long-stay intensive care unit patients*

Research Integration and Management Scripps Clinical Research Services Scripps Health La Jolla, CA * See also p. 461. The author has not disclosed any potential conflicts of interest.

The Effect of Strict Blood Glucose Control on Biliary Sludge and Cholestasis in Critically Ill Patients

Cholestatic liver dysfunction and biliary sludge are common problems in critically ill patients. No specific strategies have been described to prevent cholestasis and biliary sludge in the intensive care unit (ICU). We examined liver dysfunction and biliary sludge prospectively in a large medical long-stay ICU population and hypothesized that tight glycemic control with intensive insulin therapy (IIT) reduces cholestasis and biliary sludge. This study was a preplanned subanalysis of 658 long-stay (at least a fifth day) ICU patients out of a large randomized controlled trial (n = 1200), studying the effects of IIT on the outcome of medical critical illness. Patients were allocated to either IIT (glycemia 80-110 mg/dl) or conventional insulin therapy (CIT) requiring insulin above a glycemia of 215 mg/dl. Different patterns of liver dysfunction were studied based on daily blood sample analysis, and biliary sludge was evaluated by ultrasonography. On admission, cholestasis was present in 17% of patients (n = 649), increasing to 20% on d 10 (n = 347), whereas ischemic hepatitis decreased from 3.4% (n = 588) to less than 1% (n = 328). IIT significantly decreased biliary sludge on d 5 (50.4 vs. 66.4%, P = 0.01; n = 250). The difference did not remain significant on d 10 (57.4 vs. 66.2%, P = 0.29; n = 136). IIT also lowered the cumulative risk of cholestasis (P = 0.03). Cholestatic liver dysfunction and biliary sludge are very common during prolonged critical illness but are significantly reduced by IIT.

Intravenous glucose intake independently related to intensive care unit and hospital mortality: an argument for glucose toxicity in critically ill patients

It is assumed that the toxic effects of glucose play a role in the outcome of critically ill patients. We studied the impact of the amount of infused glucose as a determinant of mortality. A retrospective cohort study design was used as blood glucose levels in critically ill patients are nowadays tightly controlled. Long-stay critically ill patients (7-30 days). The association between the mean amount of glucose infusion and both intensive care unit (ICU) and hospital mortality was determined. We corrected for the mean glucose serum concentration, the mean dosage of insulin and for severity of illness, using the acute physiology and chronic health evaluation (APACHE II) score. Of the 2,042 admitted patients, 273 met the inclusion criteria. The mean length of stay was 14.4 days [interquartile range (IQR) 9-18]. Hospital mortality was significantly lower for patients with a mean glucose level below 8 mmol/l (30/79; 38%) compared to patients with a level above 8 mmol/l (104/194; 54%, P=0.023). Logistic stepwise multivariate regression analysis for both ICU and hospital mortality as dependent variables showed that APACHE II score and the mean daily amount of infused glucose were associated with mortality. In long-stay ICU patients without blood glucose level control, the ICU and hospital mortality was independently related to the mean amount of infused glucose. In addition, mortality in patients with a mean glucose level above 8.0 mmol/l was higher. Both these determinants of mortality can exert their effects by insulin-independent uptake of glucose with subsequent toxic intracellular effects.

Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study

IntroductionAnemia among the critically ill has been described in patients with short to medium length of stay (LOS) in the intensive care unit (ICU), but it has not been described in long-stay ICU patients. This study was performed to characterize anemia, transfusion, and phlebotomy practices in patients with prolonged ICU LOS.MethodsWe conducted a retrospective chart review of consecutive patients admitted to a medical-surgical ICU in a tertiary care university hospital over three years; patients included had a continuous LOS in the ICU of 30 days or longer. Information on transfusion, phlebotomy, and outcomes were collected daily from days 22 to 112 of the ICU stay.ResultsA total of 155 patients were enrolled. The mean age, admission Acute Physiology and Chronic Health Evaluation II score, and median ICU LOS were 62.3 ± 16.3 years, 23 ± 8, and 49 days (interquartile range 36–70 days), respectively. Mean hemoglobin remained stable at 9.4 ± 1.4 g/dl from day 7 onward. Mean daily phlebotomy volume was 13.3 ± 7.3 ml, and 62% of patients received a mean of 3.4 ± 5.3 units of packed red blood cells at a mean hemoglobin trigger of 7.7 ± 0.9 g/dl after day 21. Transfused patients had significantly greater acuity of illness, phlebotomy volumes, ICU LOS and mortality, and had a lower hemoglobin than did those who were not transfused. Multivariate logistic regression analysis identified the following as independently associated with the likelihood of requiring transfusion in nonbleeding patients: baseline hemoglobin, daily phlebotomy volume, ICU LOS, and erythropoietin therapy (used almost exclusively in dialysis dependent renal failure in this cohort of patients). Small increases in average phlebotomy (3.5 ml/day, 95% confidence interval 2.4–6.8 ml/day) were associated with a doubling in the odds of being transfused after day 21.ConclusionAnemia, phlebotomy, and transfusions, despite low hemoglobin triggers, are common in ICU patients long after admission. Small decreases in phlebotomy volume are associated with significantly reduced transfusion requirements in patients with prolonged ICU LOS.

Longitudinal pattern of glutamine/glutamate balance across the leg in long-stay intensive care unit patients

Background & Aims: Progressive muscle wasting is a characteristic feature of patients treated at the intensive care unit (ICU). As a consequence, endogenous glutamine production by skeletal muscle may be compromised. We investigated the time pattern of the glutamine and glutamate net balance across the leg in long-stay ICU patients. Methods: Critically ill patients with multiple organ failure that were expected to stay in the ICU for more than 3 days were included in a longitudinal study. Possible changes in amino acid net balance over the leg muscle were investigated overtime. The patients ( n=20) were studied descriptively every third or fourth day, on a total of 2–7 occasions. Main results: The glutamine net release from leg muscles did not change significantly during the initial 2 weeks of ICU stay and was not related to the plasma concentration of glutamine. The net uptake of glutamate across the leg muscles was unaltered during this time period, but it was found to correlate statistically with both the arterial glutamate concentration and the glutamine net release. A continuous net release of phenylalanine indicated a progressive net loss of muscle protein in these patients. Conclusion: The net release of glutamine from skeletal muscle does not decrease in stabilized critically ill patients with multiple organ failure over the initial 2 weeks of ICU stay, despite progressive muscle wasting.

Further evidence for the beneficial effects of glutamine in the nutrition of ICU patients

Appropriate nutrition to patients in the intensive care unit (ICU) is an important modality of treatment. Lack of knowledge and overenthusiasm have resulted in nutrition-related complications, which are unacceptable. In the literature, there have been several reports indicating that all the beneficial effects of nutrition may be outweighed by the complications. Although there is overwhelming evidence that starvation or semistarvation eventually leads to death, this has not been accepted as a fact in ICU patients. There are no prospective randomized controlled clinical trials on this point because such a trial would not be considered ethically acceptable. Even so, hypocaloric nutrition in long-stay ICU patients is probably fairly common. Glutamine is an amino acid, which is a natural constituent of conventional food. However, due to instability in aqueous solution, it has not been a part of intravenous nutrition. In the literature, there is massive documentation concerning the central role of glutamine in amino acid and carbohydrate metabolism. In many experimental settings, such as cell cultures, there is no cell-growth unless the medium contains a certain concentration of glutamine. Concerning the clinical advantage of glutamine-containing nutrition versus nutrition that does not contain glutamine for ICU patients, the literature is unfortunately not very extensive. There is only one prospective controlled randomized trial. 1 Although it represents high-quality work, there are some limitations, such as a comparatively small number of patients and the study being executed in one center. In addition, many studies have focused on various aspects of morbidity as the endpoint. The strength of the documentation is the demonstration of positive effects or, in some cases, no significant effect, but so far there has been no study showing a negative effect. Nevertheless, taken together, the available documentation for glutamine-supplemented nutrition is the best documentation of a specific nutrient that exists today. In this and the previous issues of Nutrition, there are two more articles containing evidence that glutamine has a beneficial effect on ICU-associated infections. The study by Conejero et al. in the present issue is a multicenter study on the use of enteral glutamine demonstrating a reduced frequency of ICU infections. The study shows some similarities with a study containing only trauma patients from one center. 2 However, this study shows a similar result in a more mixed patient group, with patients from several centers receiving enteral nutrition support. The design is similar, with an adequate supply of enteral nutrition and an adequate amount of glutamine. The second article is a follow-up of the study by Griffiths et al. 3 It is a post hoc analysis of bacteriologic and mycologic agents found in cultures from ICU patients. It showed that glutamine-treated patients had fewer serious infections and less frequent hematogenic spread of Candida albicans. This information adds to our understanding of the beneficial effects of glutamine. Today we try to use evidence-based medicine to guide our decision making, which means using the best available information. The results published in this issue of Nutrition add evidence to the advantage of using glutamine-supplemented nutrition in ICU patients, but we are all waiting for a prospective randomized controlled trial with mortality as the endpoint in ICU patients. If one can anticipate a reduction in ICU mortality from, say, 30% to 25%, 2500 ICU patients are needed. Because nutrition is a problem primarily for long-stay patients in the ICU, this will necessitate an international multicenter study to recruit a sufficient number of patients. Meanwhile, we have to rely on existing information from a number of studies representing circumstantial evidence and, perhaps equally important, the absence of reports of severe complications.