Survivors Of Critical Illness Research Articles

Intensive care unit-acquired weakness and the COVID-19 pandemic: A clinical review.

Patients with severe cases of coronavirus disease 2019 (COVID-19) often become critically ill requiring intensive care unit (ICU) management. These individuals are at risk for developing ICU-acquired weakness (ICUAW), a multifactorial condition in which polyneuropathy, myopathy, and/or disuse muscle atrophy result in motor weakness. This weakness is thought to contribute to the long-term functional disability frequently observed in survivors of critical illness. This review discusses the current evidence regarding the epidemiology, pathophysiology, evaluation, risk factors, and rehabilitation-specific management of ICUAW in patients with COVID-19. Because of the novelty of COVID-19, the exact prevalence of ICUAW is not well delineated among COVID-19 patients. However, ICUAW has been reported in this population with retrospective studies showing weakness occurring in up to 45.5% of patients with severe COVID-19. There are multiple risk factors for developing ICUAW among COVID-19 patients, including premorbid health status, sepsis, multiple organ failure, mechanical ventilation, immobilization, neuromuscular blockade, corticosteroid use, and glycemic control. ICUAW is more likely to occur after prolonged mechanical ventilation and long hospital stays and can be diagnosed with manual muscle and electrodiagnostic testing. Although the long-term sequela of COVID-19 after ICU stays is not fully studied, increasing evidence indicates significant risk for this population developing long-term functional impairments. Establishing postacute rehabilitation programs for COVID-19 survivors will be important for recovery of endurance, mobility, and function.

Intensive Care Unit-Specific Virtual Reality for Critically Ill Patients With COVID-19: Multicenter Randomized Controlled Trial.

BackgroundAlthough psychological sequelae after intensive care unit (ICU) treatment are considered quite intrusive, robustly effective interventions to treat or prevent these long-term sequelae are lacking. Recently, it was demonstrated that ICU-specific virtual reality (ICU-VR) is a feasible and acceptable intervention with potential mental health benefits. However, its effect on mental health and ICU aftercare in COVID-19 ICU survivors is unknown.ObjectiveThis study aimed to explore the effects of ICU-VR on mental health and on patients’ perceived quality of, satisfaction with, and rating of ICU aftercare among COVID-19 ICU survivors.MethodsThis was a multicenter randomized controlled trial. Patients were randomized to either the ICU-VR (intervention) or the control group. All patients were invited to an COVID-19 post-ICU follow-up clinic 3 months after hospital discharge, during which patients in the intervention group received ICU-VR. One month and 3 months later (4 and 6 months after hospital discharge), mental health, quality of life, perceived quality, satisfaction with, and rating of ICU aftercare were scored using questionnaires.ResultsEighty-nine patients (median age 58 years; 63 males, 70%) were included. The prevalence and severity of psychological distress were limited throughout follow-up, and no differences in psychological distress or quality of life were observed between the groups. ICU-VR improved satisfaction with (mean score 8.7, SD 1.6 vs 7.6, SD 1.6 [ICU-VR vs control]; t64=–2.82, P=.006) and overall rating of ICU aftercare (mean overall rating of aftercare 8.9, SD 0.9 vs 7.8, SD 1.7 [ICU-VR vs control]; t64=–3.25; P=.002) compared to controls. ICU-VR added to the quality of ICU aftercare according to 81% of the patients, and all patients would recommend ICU-VR to other ICU survivors.ConclusionsICU-VR is a feasible and acceptable innovative method to improve satisfaction with and rating of ICU aftercare and adds to its perceived quality. We observed a low prevalence of psychological distress after ICU treatment for COVID-19, and ICU-VR did not improve psychological recovery or quality of life. Future research is needed to confirm our results in other critical illness survivors to potentially facilitate ICU-VR’s widespread availability and application during follow-up.Trial RegistrationNetherlands Trial Register NL8835; https://www.trialregister.nl/trial/8835International Registered Report Identifier (IRRID)RR2-10.1186/s13063-021-05271-z

MicroRNA regulatory networks associated with abnormal muscle repair in survivors of critical illness.

BackgroundIntensive care unit (ICU)‐acquired weakness is characterized by muscle atrophy and impaired contractility that may persist after ICU discharge. Dysregulated muscle repair and regeneration gene co‐expression networks are present in critical illness survivors with persistent muscle wasting and weakness. We aimed to identify microRNAs (miRs) regulating the gene networks and determine their role in the self‐renewal of muscle in ICU survivors.MethodsMuscle whole‐transcriptome expression was assessed with microarrays in banked quadriceps biopsies obtained at 7 days and 6 months post‐ICU discharge from critically ill patients (n = 15) in the RECOVER programme and healthy individuals (n = 8). We conducted an integrated miR–messenger RNA analysis to identify miR/gene pairs associated with muscle recovery post‐critical illness and evaluated their impact on myoblast proliferation and differentiation in human AB1167 and murine C2C12 cell lines in vitro. Select target genes were validated with quantitative PCR.ResultsTwenty‐two miRs were predicted to regulate the Day 7 post‐ICU muscle transcriptome vs. controls. Thirty per cent of all differentially expressed genes shared a 3'UTR regulatory sequence for miR‐424‐3p/5p, which was 10‐fold down‐regulated in patients (P < 0.001) and correlated with quadriceps size (R = 0.86, P < 0.001), strength (R = 0.75, P = 0.007), and physical function (Functional Independence Measures motor subscore, R = 0.92, P < 0.001) suggesting its potential role as a master regulator of early recovery of muscle mass and strength following ICU discharge. Network analysis demonstrated enrichment for cellular respiration and muscle fate commitment/development related genes. At 6 months post‐ICU discharge, a 14‐miR expression signature, including miRs‐490‐3p and ‐744‐5p, identified patients with muscle mass recovery vs. those with sustained atrophy. Constitutive overexpression of the novel miR‐490‐3p significantly inhibited AB1167 and C2C12 myoblast proliferation (cell count AB1167 miR‐490‐3p mimic or scrambled‐miR transfected myoblasts 7926 ± 4060 vs. 14 159 ± 3515 respectively, P = 0.006; proportion Ki67‐positive nuclei AB1167 miR‐490‐3p mimic or scrambled‐miR transfected myoblasts 0.38 ± 0.07 vs. 0.54 ± 0.06 respectively, P < 0.001; proliferating cell nuclear antigen expression AB1167 miR‐490‐3p mimic or scrambled‐miR transfected myoblasts 11.48 ± 1.97 vs. 16.75 ± 1.19 respectively, P = 0.040). Constitutive overexpression of miR‐744‐5p, a known regulator of myogenesis, significantly inhibited AB1167 and C2C12 myoblast differentiation (fusion index AB1167 miR‐744‐5p mimic or scrambled‐miR transfected myoblasts 8.31 ± 7.00% vs. 40.29 ± 9.37% respectively, P < 0.001; myosin heavy chain expression miR‐744‐5p mimic or scrambled‐miR transfected myoblasts 0.92 ± 0.39 vs. 13.53 ± 5.5 respectively, P = 0.01).ConclusionsCombined functional transcriptomics identified 36 miRs including miRs‐424‐3p/5p, ‐490‐3p, and ‐744‐5p as potential regulators of gene networks associated with recovery of muscle mass and strength following critical illness. MiR‐490‐3p is identified as a novel regulator of myogenesis.

Experience of Post-ICU Syndrome in Critical Disease Survivors

Introduction: Surviving Intensive Care Unit (ICU) brings positive and negative feelings, depending on each person’s experience. Likewise, some patients may present with negative mental and physical consequences after discharge, causing a very complex stay at home. Aim: To understand the experience of critical illness survivors after three months of ICU discharge. Methods: Hermeneutical phenomenological study using in-depth interviews with 15 adult participants after three months of ICU discharge. Data analysis was made considering Cohen, Kahn, and Steeves’ procedures. Results: Phenomenological analysis revealed three existential themes: Changes in memory and mood, Changes in day-to-day life, and My body after ICU. Conclusion: Surviving ICU brings with it positive aspects such as winning a battle against death. However, psychological, emotional, and physical consequences after discharge turn it into an exhausting experience.

Patients Surviving Critical COVID-19 have Impairments in Dual-task Performance Related to Post-intensive Care Syndrome.

ObjectiveThe purpose was to examine Dual Task (DT) performance in patients surviving severe and critical COVID-19 compared to patients with chronic lung disease (CLD). Secondarily, we aimed to determine the psychometric properties of the Timed Up and Go (TUG) test in patients surviving COVID-19.DesignProspective, cross-sectional, observational study.SettingAcademic medical center within United States.PatientsNinety-two patients including 36 survivors of critical COVID-19 that required mechanical ventilation (critical-COVID), 20 patients recovering from COVID-19 that required supplemental oxygen with hospitalization (severe-COVID), and 36 patients with CLD serving as a control group.Measurements and Main ResultsPatients completed the TUG, DT-TUG, Short Physical Performance Battery (SPPB), and Six Minute Walk Test (6MWT) 1-month after hospital discharge. A subset of patients returned at 3-months and repeated testing to determine the minimal detectable change (MDC). Critical-COVID group (16.8 ± 7.3) performed the DT-TUG in significantly slower than CLD group (13.9 ± 4.8 s; P = .024) and Severe-COVID group (13.1 ± 5.1 s; P = .025). Within-subject difference between TUG and DT-TUG was also significantly worse in critical-COVID group (−21%) compared to CLD (−10%; P = .012), even despite CLD patients having a higher comorbid burden (P < .003) and older age (P < .001). TUG and DT-TUG demonstrated strong to excellent construct validity to the chair rise test, gait speed, and 6MWT for both COVID-19 groups (r = −0.84to 0.73, P < .05). One- and 3-months after hospital discharge there was a floor effect of 14% (n = 5/36) and 5.2% (n = 1/19), respectively for patients in the critical-COVID group. Ceiling effects were noted in four (11%) critical-COVID, six (30%) severe-COVID patients for the TUG and DT-TUG at 1-month.ConclusionThe ability to maintain mobility performance in the presence of a cognitive DT is grossly impaired in patients surviving critical COVID-19. DT performance may subserve the understanding of impairments related to Post-intensive care syndrome (PICS) for survivors of critical illness.

A Decade of Post-Intensive Care Syndrome: A Bibliometric Network Analysis.

Background and Objectives: In 2012, the umbrella term post-intensive care syndrome (PICS) was introduced to capture functional long-term impairments of survivors of critical illness. We present a bibliometric network analysis of the PICS research field. Materials and Methods: The Web of Science core database was searched for articles published in 2012 or later using ‘post-intensive care syndrome’ and variant spellings. Using VOSviewer, we computed co-authorship networks of countries, institutions, and authors, as well as keyword co-occurrence networks. We determined each country’s relative research effort and Category Normalized Citation Index over time and analyzed the 100 most-cited articles with respect to article type, country of origin, and publishing journal. Results: Our search yielded 379 articles, of which 373 were analyzed. Annual PICS research output increased from 11 (2012) to 95 articles (2020). Most PICS research originates from the US, followed by England, Australia, the Netherlands, and Germany. We found various collaborations between countries, institutions, and authors, with recent collaborative networks of English and Australian institutions. Article keywords cover aspects of cognitive, mental health, and physical impairments, and more recently, COVID-19. Only a few keywords and articles pertained to PICS prevention and treatment. Conclusions: Our analysis of Web of Science-indexed PICS articles highlights the stark increase in PICS research output in recent years, primarily originating from US- and Europe-based authors and institutions. Despite the research field’s growth, knowledge gaps with respect to PICS prevention and treatment remain.

Analysis of the characteristics and influencing factors of early comprehensive symptoms in elderly patients after ICU

Research methods: In order to solve the early syndrome of elderly patients after ICU and provide reference for the treatment of elderly patients with post ICU syndrome, this paper studied the characteristics of early symptoms of elderly patients and analyzed the influencing factors. This article describes the frequency of newly acquired cognitive impairment, activities of daily living (ADL) and depression among the elderly survivors of critical illness. Finally, the predictive factors of asymptomatic elderly patients with post intensive care syndrome (PICS) (i.e., no PICS problems) were evaluated and analyzed. Subjects: This article selects many elderly ICU patients from the internal medicine and surgery departments of ICU in major hospitals in a city. They all have respiratory failure, shock and other characteristics, ignoring patients with cognitive impairment or ADL disability. To study the characteristics of the above elderly patients at 3 and 12 months after discharge. The research samples were divided into eight groups, and the mental health problems, cognitive problems and physical disability problems of these eight groups of elderly patients were studied in combination. By using the control variable method and multivariable logistic regression analysis, the relationship between age, education level, weakness report entering ICU, time of mechanical ventilation, delirium and severe sepsis and the probability of no PICS was obtained. Study data: The sample is 406 patients, of whom the average age is 61 years old. The study found that 64% of the elderly patients had one or more PICS problems at 3 months, and the total number of patients with more than 2 PICS accounted for 25% of the total proportion, while only 6% of patients with more than 3 PICS; When the time was 12 months, the proportion of patients with one or more PICS problems decreased to 56%, and the total number of patients with more than 2 PICS accounted for 21% of the total proportion, while only 4% of patients with more than 3 PICS. This means that when the recovery time of patients after ICU is longer and longer, the proportion of patients will gradually decline. In addition, the longer the elderly patients were educated, the greater the possibility of no PICS. The data showed that at 3 and 12 months, P<0.001. The low probability of no PICS was associated with more severe frailty. The data showed that P=0.005 at 3 months and P=0.048 at 12 months. Conclusion: In this multicenter cohort study, most survivors have one or more PICS problems, but only 1/4 of the patients have merger problems. Future studies need to better understand the heterogeneous subtypes of PICS and identify modifiable risk factors. In the elderly patient group, the incidence rate of PICS has nothing to do with whether they have received education, but it is related to the doctor's weak diagnosis report of elderly patients when they enter the ICU. The lower the score of the report, the higher the incidence rate of PICS.

Hospital re-admission after critical care survival: a systematic review and meta-analysis.

Survivors of critical illness frequently require increased healthcare resources after hospital discharge. We undertook a systematic review and meta-analysis to assess hospital re-admission rates following critical care admission and to explore potential re-admission risk factors. We searched the MEDLINE, Embase and CINAHL databases on 05 March 2020. Our search strategy incorporated controlled vocabulary and text words for hospital re-admission and critical illness, limited to the English language. Two reviewers independently applied eligibility criteria and assessed quality using the Newcastle Ottawa Score checklist and extracted data. The primary outcome was acute hospital re-admission in the year after critical care discharge. Of the 8851 studies screened, 87 met inclusion criteria and 41 were used within the meta-analysis. The analysis incorporated data from 3,897,597 patients and 741,664 re-admission episodes. Pooled estimates for hospital re-admission after critical illness were 16.9% (95%CI: 13.3-21.2%) at 30 days; 31.0% (95%CI: 24.3-38.6%) at 90 days; 29.6% (95%CI: 24.5-35.2%) at six months; and 53.3% (95%CI: 44.4-62.0%) at 12 months. Significant heterogeneity was observed across included studies. Three risk factors were associated with excess acute care rehospitalisation one year after discharge: the presence of comorbidities; events during initial hospitalisation (e.g. the presence of delirium and duration of mechanical ventilation); and subsequent infection after hospital discharge. Hospital re-admission is common in survivors of critical illness. Careful attention to the management of pre-existing comorbidities during transitions of care may help reduce healthcare utilisation after critical care discharge. Future research should determine if targeted interventions for at-risk critical care survivors can reduce the risk of subsequent rehospitalisation.

Post-intensive care syndrome in pediatrics

The term “Post-intensive care syndrome” describe new impairments after critical illness, that worsen physical, cognitive, or mental health, and persist after acute care hospitalization. a bibliographic search was carried out using the Medline database. The search period was from 2012 to 2020 using keywords. Emerging evidence suggests that there are significant and persistent physical, cognitive, and psychiatric morbidities among adult and pediatric survivors of critical illness. In this population it can also affect the “social health” sphere. The families of hospitalized patients often manifest psychological symptoms. For prevention and management there are various tools, the package of measures "ABCDEFGH", the conformation and organization of the health team, early mobilization and physical rehabilitation, nutritional contribution, environmental management, intensive care unit diaries and support between pairs. Each patient´s situation is unique and the challenges they face may require different interventions. These should be studied to increase the available evidence in the pediatric population. We still do not have a specific instrument to monitor the syndrome in pediatrics or information on long-term sequelae in children.

Post-Intensive Care Unit Syndrome in a Cohort of COVID-19 Survivors in New York City.

Rationale: The coronavirus disease (COVID-19) pandemic has led to a dramatic increase in the number of survivors of critical illness. These survivors are at increased risk for physical, psychological, and cognitive impairments known collectively as post-intensive care syndrome (PICS). Little is known about the prevalence of PICS in COVID-19 survivors. Objectives: To report the prevalence of physical, psychological, and cognitive impairment among COVID-19 intensive care unit (ICU) survivors receiving follow-up care in an ICU recovery clinic, to assess for associations between PICS and ICU-related factors, and to compare the cohort of ICU survivors who attended a post-ICU clinic with a cohort of ICU survivors who did not. Methods: We performed a retrospective cohort study of COVID-19 ICU survivors admitted from March to May 2020 who were subsequently seen in a post-ICU recovery clinic in New York City. We abstracted medical chart data on available clinical screening instruments for physical, psychological, and cognitive impairment. Associations between these outcomes and care-related variables were tested. Baseline characteristics and in-hospital treatments of the post-ICU clinic cohort were compared with those of COVID-19 ICU survivors from the same institution who were not seen in the post-ICU clinic. Results: Eighty-seven COVID-19 ICU survivors were seen in our post-ICU recovery clinic. The median age was 62 years, and 74% were male. The median length of hospitalization was 51 days, and the median length of ICU stay was 22 days. At the post-ICU follow-up visit, 29%, 21%, and 13% of patients reported clinically significant levels of depressive symptoms, anxiety, and post-traumatic stress disorder symptoms, respectively. Twenty-five percent had cognitive impairment. The overall prevalence of PICS was 90%. There were no associations between length of ICU stay, delirium, and exposure to benzodiazepines, steroids, or systemic paralytics with positive screening results for physical, psychological, or cognitive impairment. Baseline characteristics and ICU-related factors were similar in the cohort of COVID-19 ICU survivors who attended the ICU recovery clinic and those who did not. Conclusions: PICS is common in COVID-19 survivors. We did not find any association with length of ICU stay or the use of benzodiazepines, steroids, or paralytics.

Long-Term Follow up of Renal and Other Acute Organ Failure in Survivors of Critical Illness Due to Covid-19.

BackgroundLittle is known about the long-term health sequelae and outcomes of various organ failures in ICU survivors of Covid-19. The aim of our research was to study the characteristics of 120-day ICU survivors of the initial pandemic surge and report their long term (>6 months) outcomes.MethodsWe conducted a telephone questionnaire-based follow up study of 120- day survivors of Covid-19 admitted to ICUs at Montefiore Medical Center, Bronx, NY from 3/10/2020 to 4/11/2020. The study period was 2 months (11/1/2020-12/31/2020).Results126 out of 300 (42%) survived to 120-days post-hospital discharge. The median age of survivors was 54 (47-61) years. Seventy-eight (62%) patients developed acute kidney injury (AKI); thirty-five (44.9%) of them required renal replacement therapy (RRT). One hundred-five (83.3%) required invasive mechanical ventilation; ten of them required tracheotomy. 103 (81.7%) completed the telephone questionnaire-based study, at a median (IQR) of 216.5 (200-234.5) days after hospital discharge. 29 (28.2%) patients reported persistent shortness of breath, 24, (23.3%) complained of persistent cough, and persistent anosmia in 9 (8.8%). AKI resolved completely in 58 (74.4%) patients. Of 35 AKI patients who required initiation of RRT during hospitalization, 27 (77%) were liberated from RRT and 20 (57%) had resolution of AKI. Of 20 patients without AKI resolution, 12 developed chronic kidney disease, whereas 8 still require RRT. Thirty-three (32.4%) patients developed post-traumatic stress disorder (PTSD) and 10 (11.8%) reported major depression. Many of the patients (68%) regained baseline functional status. Readmissions occurred in 22.3% patients within first 6 months after discharge.ConclusionPersistent symptoms of long Covid have been reported in ICU survivors of Covid-19 for extended durations. Outcomes of Covid-19 associated acute kidney injury are excellent. There is a high incidence of PTSD and depression in COVID-19 ICU survivors. Functional outcomes are good, but these patients remain at increased risk of hospital readmission.

Characteristics and influence on quality of life of new-onset pain in critical COVID-19 survivors.

BackgroundPain is a clinical feature of COVID‐19, however, data about persistent pain after hospital discharge, especially among ICU survivors is scarce. The aim of this study was to explore the incidence and characteristics of new‐onset pain and its impact on Health‐Related Quality of Life (HRQoL), and to quantify the presence of mood disorders in critically ill COVID‐19 survivors.MethodsThis is a preliminary report of PAIN‐COVID trial (NCT04394169) presenting a descriptive analysis in critically ill COVID‐19 survivors, following in person interview 1 month after hospital discharge. Pain was assessed using the Brief Pain Inventory, the Douleur Neuropathique 4 questionnaire and the Pain Catastrophizing Scale. HRQoL was evaluated with the EQ 5D/5L, and mood disorders with the Hospital Anxiety and Depression Scale (HADS).ResultsFrom 27 May to 19 July 2020, 203 patients were consecutively screened for eligibility, and 65 were included in this analysis. Of these, 50.8% patients reported new‐onset pain; 38.5% clinically significant pain (numerical rating score ≥3 for average pain intensity); 16.9% neuropathic pain; 4.6% pain catastrophizing thoughts, 44.6% pain in ≥2 body sites and 7.7% widespread pain. Patients with new‐onset pain had a worse EQ‐VAS and EQ index value (p < 0.001). Pain intensity was negatively correlated to both the former (Spearman ρ: −0.546, p < 0.001) and the latter (Spearman ρ: −0.387, p = 0.001). HADS anxiety and depression values equal or above eight were obtained in 10.8% and 7.7% of patients, respectively.ConclusionNew‐onset pain in critically ill COVID‐19 survivors is frequent, and it is associated with a lower HRQoL.Trial registration No.: NCT04394169. Registered 19 May 2020. https://clinicaltrials.gov/ct2/show/NCT04394169.SignificanceA substantial proportion of severe COVID‐19 survivors may develop clinically significant persistent pain, post‐intensive care syndrome and chronic ICU‐related pain. Given the number of infections worldwide and the unprecedented size of the population of critical illness survivors, providing information about the incidence of new‐onset pain, its characteristics, and its influence on the patients’ quality of life might help establish and improve pain management strategies.

Intravenous iron to treat anaemia following critical care: a multicentre feasibility randomised trial

BackgroundAnaemia is common and associated with poor outcomes in survivors of critical illness. However, the optimal treatment strategy is unclear. MethodsWe conducted a multicentre, feasibility RCT to compare either a single dose of ferric carboxymaltose 1000 mg i.v. or usual care in patients being discharged from the ICU with moderate or severe anaemia (haemoglobin ≤100 g L−1). We collected data on feasibility (recruitment, randomisation, follow-up), biological efficacy, and clinical outcomes. ResultsNinety-eight participants were randomly allocated (49 in each arm). The overall recruitment rate was 34% with 6.5 participants recruited on average per month. Forty-seven of 49 (96%) participants received the intervention. Patient-reported outcome measures were available for 79/93 (85%) survivors at 90 days. Intravenous iron resulted in a higher mean (standard deviation [sd]) haemoglobin at 28 days (119.8 [13.3] vs 106.7 [14.9] g L−1) and 90 days (130.5 [15.1] vs 122.7 [17.3] g L−1), adjusted mean difference (10.98 g L−1; 95% confidence interval [CI], 4.96–17.01; P<0.001) over 90 days after randomisation. Infection rates were similar in both groups. Hospital readmissions at 90 days post-ICU discharge were lower in the i.v. iron group (7/40 vs 15/39; risk ratio=0.46; 95% CI, 0.21–0.99; P=0.037). The median (inter-quartile range) post-ICU hospital stay was shorter in the i.v. iron group but did not reach statistical significance (5.0 [3.0–13.0] vs 9.0 [5.0–16.0] days, P=0.15). ConclusionA large, multicentre RCT of i.v. iron to treat anaemia in survivors of critical illness appears feasible and is necessary to determine the effects on patient-centred outcomes. Clinical trial registrationISRCTN13721808 (www.isrctn.com).

Old critically ill COVID‐19 survivors: Patient and in‐hospital factors associated with cognitive dysfunction

BackgroundCognitive dysfunction (CD) commonly occurs in survivors of critical illness, namely in those with severe respiratory failure, invasive mechanical ventilation (IMV), deep sedation and delirium. Many critically ill patients with COVID‐19 are also expected to have an increased risk of CD, which may be exacerbated by specific conditions of hospitalization during COVID‐19 pandemic. This study aimed to estimate the frequency of post‐discharge CD in first wave COVID‐19 survivors and to identify baseline and in‐hospital associated factors.MethodsThis study is part of a multidisciplinary longitudinal project (MAPA‐Mental health in critically ill COVID‐19 patients), that is being conducted in Intensive Care Medicine Department of a Portuguese University Hospital. Patients >60 years, admitted due to COVID‐19‐associated Pneumonia, were included. Exclusion criteria were: Intensive Care Unit (ICU) length of stay (LoS)≤24h, terminal illness, major sensory loss or inability to communicate at the time of follow‐up. Participants were evaluated with Six‐item Cognitive Impairment Test (6CIT) by telephone. Baseline demographic, clinical and in‐hospital data were collected, including sedation, respiratory support, major complications and LoS. Patients with and without CD after‐discharge were compared.ResultsThirty‐two patients were included, with a median age of 72(IQR:64‐76) years, mostly were male (66%) and none had previous clinical registry of cognitive impairment or dementia. Nosocomial infection (75%) and difficult weaning from MV (63%) were the most frequent complications. Deep sedation was used in 81% of the patients (median=20 days; IQR:15‐42). About 81% needed IMV and 13% were supported with Extracorporeal Membrane Oxygenation (ECMO). Median ICU and hospital LoS were 29(IQR:144‐56) and 66(IQR:33‐102) days, respectively. Follow‐up assessment occurred 93.4 days (IQR:68‐120) after‐discharge. Based on 6CIT, 16% of survivors had CD. Comparing both groups, those with CD were older (73vs.64; p=0.020), had a higher duration of IMV (73vs.22; p=0.017) and mostly were supported with ECMO (75%vs.25%; p=0.008).ConclusionData suggest that CD is more frequent among older COVID‐19 survivors, and those who needed prolonged IMV and ECMO support. Despite full clarification of all mechanisms involved, these findings highlight the importance of a timely and organized post‐intensive care response composed by multidisciplinary teams to optimize assistance to survivors of critical illness.

A pilot study of trained ICU doulas providing early psychological support to critically ill patients

BackgroundOver a third of critical illness survivors suffer from mental health problems following hospitalization. Memories of delusional experiences are a major risk factor. In this project, ICU doulas delivered a unique positive suggestion intervention targeting the vulnerable time period during critical illness when these memories are formed.MethodsAdult critically ill patients were recruited for this single-arm, prospective pilot study. These ICU patients received a positive suggestion intervention daily during their ICU stay in parallel with their medical treatment. The intervention was designed to be delivered over a minimum of two sessions. Feasibility was defined as intervention delivery on ≥ 70% of ICU days after patient enrollment. As a secondary analysis, psychometric questionnaires were compared to those of a historic control cohort of patients receiving standard care in the ICU using adjusted linear regression models.ResultsOf the 97 patients who received the intervention and were alive at the end of their ICU course, 54 were excluded from analyses mostly for having received only one session because of a short ICU length of stay of < 2 days, transitioning to comfort care or not wanting to answer the study questionnaires. Forty-three patients who completed 2 or more sessions of the positive therapeutic suggestion intervention provided by two trained ICU doulas received it for a median of 4 days (IQR 3, 5), with each session lasting for a median of 20 min (IQR 14, 25). The intervention was delivered on 71% of days, meeting our pre-determined feasibility goal. Compared to historical controls (N = 299), patients receiving the intervention had higher severity of illness and longer length of stay. When adjusted for baseline differences, patients both with and without mechanical ventilation who received the intervention scored lower on the Hospital Anxiety and Depression Scale (HADS)—Depression subscale. The intervention was also associated with reduced HADS-Anxiety subscale among ventilated patients.ConclusionsPositive therapeutic suggestion delivered by ICU doulas is feasible in the ICU setting. A randomized trial is warranted to better delineate the role that positive suggestion and ICU doulas may play in ongoing interprofessional efforts to humanize critical care medicine.The study was registered on clinicaltrials.gov (NCT03736954) on 03/14/2018 prior to the first patient enrollment https://clinicaltrials.gov/ct2/show/NCT03736954?cond=ICU+Doulas+Providing+Psychological+Support&draw=2&rank=1.

Virtual Reality-Based Early Neurocognitive Stimulation in Critically Ill Patients: A Pilot Randomized Clinical Trial.

This study focuses on the application of a non-immersive virtual reality (VR)-based neurocognitive intervention in critically ill patients. Our aim was to assess the feasibility of direct outcome measures to detect the impact of this digital therapy on patients’ cognitive and emotional outcomes. Seventy-two mechanically ventilated adult patients were randomly assigned to the “treatment as usual” (TAU, n = 38) or the “early neurocognitive stimulation” (ENRIC, n = 34) groups. All patients received standard intensive care unit (ICU) care. Patients in the ENRIC group also received adjuvant neurocognitive stimulation during the ICU stay. Outcome measures were a full neuropsychological battery and two mental health questionnaires. A total of 42 patients (21 ENRIC) completed assessment one month after ICU discharge, and 24 (10 ENRIC) one year later. At one-month follow-up, ENRIC patients had better working memory scores (p = 0.009, d = 0.363) and showed up to 50% less non-specific anxiety (11.8% vs. 21.1%) and depression (5.9% vs. 10.5%) than TAU patients. A general linear model of repeated measures reported a main effect of group, but not of time or group–time interaction, on working memory, with ENRIC patients outperforming TAU patients (p = 0.008, ηp2 = 0.282). Our results suggest that non-immersive VR-based neurocognitive stimulation may help improve short-term working memory outcomes in survivors of critical illness. Moreover, this advantage could be maintained in the long term. An efficacy trial in a larger sample of participants is feasible and must be conducted.

Prognosis and antibody profiles in survivors of critical illness from COVID-19: a prospective multicentre cohort study

BackgroundThere is a need to assess the long-term outcomes of survivors of critical illness from COVID-19. MethodsNinety-two survivors of critical illness from COVID-19 from four hospitals in Hubei Province, China participated in this prospective cohort study. Multiple characteristics, including lung function (lung volumes, diffusing capacity for carbon monoxide, chest computed tomography scores, and walking capacity); immune status (SARS-CoV-2-neutralising antibody and all subtypes of immunoglobulin (Ig) G against SARS-CoV-2, immune cells in response to ex vivo antigen peptide stimuli, and lymphocyte count and its subtypes); liver, coagulation, and kidney functions; quality of life; cognitive function; and mental status, were assessed after 3, 6, and 12 months of follow-up. ResultsAmongst the 92 enrolled survivors, 72 (78%) patients required mechanical ventilation. At 12 months, the predicted percentage diffusing capacity of lung for carbon monoxide was 82% (inter-quartile range [IQR]: 76–97%) with a residual volume of 77 (64–88)%. Other lung function parameters and the 6-min walk test improved gradually over time and were almost back to normal by 12 months. The titres of IgG and neutralising antibody to COVID-19 remained high at 12 months compared with those of controls who were not infected with COVID-19, although IgG titres decreased significantly from 34.0 (IQR: 23.8–74.3) to 15.0 (5.8–24.3) AU ml−1 (P<0.001), whereas neutralising antibodies decreased from 29.99 (IQR: 19.43–53.93) AU ml−1 at 6 months to 19.75 (13.1–29.8) AU ml−1 (P<0.001) at 12 months. In general, liver, kidney, physical, and mental functions also improved over time. ConclusionsSurvivors of critical illness from COVID-19 show some persistent long-term impairments in lung function. However, a majority of these tests were normal by 12 months. These patients still had detectable levels of neutralising antibodies against SARS-CoV-2 and all types of IgG at 12 months, but the levels had declined over this time period. Clinical trial registrationNone.

Posttraumatic stress phenomena in critical illness and intensive care survivors

The intensive care unit (ICU) within a hospital is typically thought of as a place for the provision of patient care for a life-threatening emergency. Less frequently do we consider it an integral part of disaster response. The COVID-19 pandemic is a public health disaster that has caused surges of critically ill patients requiring treatment in intensive care units (ICUs). However, it is important to bear in mind that survival of a critical illness can come at a cost, including to mental health. Being critically ill and requiring life-saving treatments is extremely stressful, and survivors frequently have substantial decrements in physical functioning, cognition, and emotional health. Remarkably, one in five critical illness survivors has clinically significant symptoms of posttraumatic stress disorder (PTSD). Risk factors, or markers of risk, include prior anxiety and depression, high doses of sedative medications in the intensive care unit (ICU), memories of nightmare-like experiences in the ICU, and emotional distress in early recovery. As with PTSD in other contexts, social support is a protective factor. ICU follow-up clinics, in-ICU psychological interventions, ICU diaries, post-ICU telephonic and computer-based cognitive-behavioral interventions, and virtual reality interventions all show promise in preventing long-term PTSD in critical illness survivors, perhaps particularly in those with substantial emotional distress in early recovery. However, awareness regarding this problem is still growing, as are changes to post-ICU care delivery. Hopefully, improved awareness on the part of the psychiatric community will help with recovery from the COVID-19 pandemic disaster.

Aerobic exercise capacity in long-term survivors of critical illness: secondary analysis of the post-EPaNIC follow-up study.

PurposeTo evaluate aerobic exercise capacity in 5-year intensive care unit (ICU) survivors and to assess the association between severity of organ failure in ICU and exercise capacity up to 5-year follow-up.MethodsSecondary analysis of the EPaNIC follow-up cohort (NCT00512122) including 433 patients screened with cardiopulmonary exercise testing (CPET) between 1 and 5 years following ICU admission. Exercise capacity in 5-year ICU survivors (N = 361) was referenced to a historic sedentary population and further compared to demographically matched controls (N = 49). In 5-year ICU survivors performing a maximal CPET (respiratory exchange ratio > 1.05, N = 313), abnormal exercise capacity was defined as peak oxygen consumption (VO2peak) < 85% of predicted peak oxygen consumption (%predVO2peak), based on the historic sedentary population. Exercise liming factors were identified. To study the association between severity of organ failure, quantified as the maximal Sequential Organ Failure Assessment score during ICU-stay (SOFA-max), and exercise capacity as assessed with VO2peak, a linear mixed model was built, adjusting for predefined confounders and including all follow-up CPET studies.ResultsExercise capacity was abnormal in 118/313 (37.7%) 5-year survivors versus 1/48 (2.1%) controls with a maximal CPET, p < 0.001. Aerobic exercise capacity was lower in 5-year survivors than in controls (VO2peak: 24.0 ± 9.7 ml/min/kg versus 31.7 ± 8.4 ml/min/kg, p < 0.001; %predVO2peak: 94% ± 31% versus 123% ± 25%, p < 0.001). Muscular limitation frequently contributed to impaired exercise capacity at 5-year [71/118 (60.2%)]. SOFA-max independently associated with VO2peak throughout follow-up.ConclusionsCritical illness survivors often display abnormal aerobic exercise capacity, frequently involving muscular limitation. Severity of organ failure throughout the ICU stay independently associates with these impairments.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00134-021-06541-9.

Transitions of Care After Critical Illness-Challenges to Recovery and Adaptive Problem Solving.

Investigate the challenges experienced by survivors of critical illness and their caregivers across the transitions of care from intensive care to community, and the potential problem-solving strategies used to navigate these challenges. Qualitative design-data generation via interviews and data analysis via the framework analysis method. Patients and caregivers from three continents, identified through the Society of Critical Care Medicine's THRIVE international collaborative sites (follow-up clinics and peer support groups). Patients and caregivers following critical illness. Nil. From 86 interviews (66 patients, 20 caregivers), we identified the following major themes: 1) Challenges for patients-interacting with the health system and gaps in care; managing others' expectations of illness and recovery. 2) Challenges for caregivers-health system shortfalls and inadequate communication; lack of support for caregivers. 3) Patient and caregiver-driven problem solving across the transitions of care-personal attributes, resources, and initiative; receiving support and helping others; and acceptance. Survivors and caregivers experienced a range of challenges across the transitions of care. There were distinct and contrasting themes related to the caregiver experience. Survivors and caregivers used comparable problem-solving strategies to navigate the challenges encountered across the transitions of care.