Anna Schandl

Screening and treatment of problems after intensive care: A descriptive study of multidisciplinary follow-up

OBJECTIVES To describe a multidisciplinary intensive care follow-up and the methods used for identifying and managing physical and psychological problems in ICU survivors. METHODS Patients treated>four days in an intensive care unit (ICU) were invited three, six and 12 months after intensive care for screening of physical problems with function tests and psychological problems with the Impact of Event Scale (IES) and the Hospital Anxiety and Depression Scale (HADS). RESULTS 40 of 61 patients had clinically impaired physical function, with no ongoing physical rehabilitation at three months. Twenty-two patients received specific training instructions and 18 patients were referred for physiotherapy. 34 of 61 patients had symptoms of moderate to severe posttraumatic stress and/or symptoms of clinically significant anxiety or depression. Twelve patients accepted referral for psychiatric evaluation and treatment. CONCLUSION Multidisciplinary follow-up after intensive care can be of value in identifying untreated physical and psychological problems in ICU survivors. Liaison with specialists enables referral for identified problems. Patients screened and treated in the first six months appear to have little need for further follow-up after intensive care.

Developing an early screening instrument for predicting psychological morbidity after critical illness

IntroductionGuidelines recommend follow-up for patients after an intensive care unit (ICU) stay. Methods for identifying patients with psychological problems after intensive care would be of value, to optimize treatment and to improve adequate resource allocation in ICU follow-up of ICU survivors. The aim of the study was to develop a predictive screening instrument, for use at ICU discharge, to identify patients at risk for post-traumatic stress, anxiety or depression.MethodsTwenty-one potential risk factors for psychological problems - patient characteristics and ICU-related variables - were prospectively collected at ICU discharge. Two months after ICU discharge 252 ICU survivors received the questionnaires Post-Traumatic Stress Symptom scale -10 (PTSS-10) and Hospital Anxiety and Depression Scale (HADS) to estimate the degree of post-traumatic stress, anxiety and depression.ResultsOf the 150 responders, 46 patients (31%) had adverse psychological outcome, defined as PTSS-10 >35 and/or HADS subscales ≥8. After analysis, six predictors were included in the screening instrument: major pre-existing disease, being a parent to children younger than 18 years of age, previous psychological problems, in-ICU agitation, being unemployed or on sick-leave at ICU admission and appearing depressed in the ICU. The total risk score was related to the probability for adverse psychological outcome in the individual patient. The predictive accuracy of the screening instrument, as assessed with area under the receiver operating characteristic curve, was 0.77. When categorizing patients in three risk probability groups - low (0 to 29%), moderate (30 to 59%) high risk (60 to 100%), the actual prevalence of adverse psychological outcome in respective groups was 12%, 50% and 63%.ConclusionThe screening instrument developed in this study may aid ICU clinicians in identifying patients at risk for adverse psychological outcome two months after critical illness. Prior to wider clinical use, external validation is needed.

Gender differences in psychological morbidity and treatment in intensive care survivors - a cohort study

IntroductionMany hospitals have initiated follow-up to facilitate rehabilitation after critical illness and intensive care, although the efficacy of such an intervention is uncertain. Studies in trauma research indicate significant differences in psychological reactions to traumatic events between men and women. Our aim, in a quasi-experimental design, was to compare psychological morbidity and treatment effects between men and women enrolled in a multidisciplinary intensive care unit (ICU) follow-up programme (follow-up group) and ICU patients not offered such follow-up (control group).MethodsMen and women treated more than four days in the ICU in 2006, before ICU follow-up started, were compared with men and women treated in 2007 and 2008, when all patients with an ICU stay of more than four days were offered ICU follow-up at 3, 6 and 12 months post-ICU. Fourteen months after ICU discharge, psychological problems were measured with Impact of Event Scale (IES) for posttraumatic stress and Hospital Anxiety and Depression Scale (HADS) for anxiety and depression.ResultsWomen with no follow-up reported significantly higher IES scores than men. Women in the follow-up group reported significantly lower IES scores compared to women in the control group, both in crude analysis and after adjusting for significant confounders/predictors (age, ICU length of stay and previous psychological problems). Furthermore, the 75th percentile for IES and HADS-Depression scores (high scores and degree of symptoms of psychological problems) in women in the follow-up group was lower than in those without follow-up (IES: -17.4 p, P <.01, HADS-depression: -4.9 p, P <.05). For men, no significant differences were found between the no follow-up and the follow-up group.ConclusionPsychological problems after critical illness and intensive care appear to be more common in women than in men. A multidisciplinary ICU follow-up may reduce the incidence of long-term symptoms of posttraumatic stress and depression for women.

Palmar skin conductance variability and the relation to stimulation, pain and the motor activity assessment scale in intensive care unit patients

IntroductionMany intensive care unit (ICU) patients describe pain and other adverse feelings that may impact long-term psychological morbidity. Sympathetically mediated palmar skin conductance variability is related to emotionally induced perspiration and correlates with pain levels in the perioperative setting but has not been studied in ICU patients.MethodsTwenty non-intubated and 20 intubated general ICU patients were included in this observational study. Patients were monitored with the MED-STORM Pain Monitoring System®. The number of skin conductance fluctuations per second (NSCF) was measured in parallel with bedside observation during one hour of intensive care, including rest, procedures and patient-staff interactions. Arousal-agitation level was monitored with the motor activity assessment scale (MAAS). Pain was monitored with the numeric rating scale (0 to 10) in patients able to communicate or by observation in patients unable to communicate.ResultsIn non-intubated patients, NSCF increased with increasing stimulation/pain but also with higher MAAS (P = 0.002). An interaction effect was found, with increased NSCF response to stimulation/pain with increasing MAAS (P < 0.001).In intubated patients, NSCF increased significantly with increasing stimulation/pain (P < 0.001). In contrast to non-intubated patients, no difference in NSCF between MAAS levels was found for any given degree of stimulation in intubated patients.ConclusionsIn critically ill patients, NSCF may be more useful evaluating emotional distress rather than pain alone. It needs to be assessed whether NSCF monitoring is clinically useful and whether controlling emotional distress with the aid of such monitoring may impact on patient care and outcomes.

Early prediction of new-onset physical disability after intensive care unit stay: a preliminary instrument

IntroductionMany intensive care unit (ICU) survivors suffer from physical disability for months after ICU stay. There is no structured method to identify patients at risk for such problems. The purpose of the study was to develop a method for early in-ICU prediction of the patient’s individual risk for new-onset physical disability two months after ICU stay.MethodsIn total, 23 potential predictors for physical disability were assessed before individual ICU discharge. Two months after ICU discharge, out of 232 eligible patients, 148 ICU survivors (64%) completed the activity of daily living (ADL) staircase questionnaire to determine new-onset physical disability.ResultsA total of 95% percent of patients had no ADL reduction prior to ICU admission. Forty-seven percent (n = 69) of questionnaire responders suffered from worsened ADL. We identified four independent predictors for new-onset physical disability: Low educational level (odds ratio (OR) = 6.8), impaired core stability (OR = 4.6), fractures (OR = 4.5) and ICU length of stay longer than two days (OR = 2.6). The predictors were included in a screening instrument. The regression coefficient of each predictor was transformed into a risk score. The sum of risk scores was related to a predicted probability for physical disability in the individual patient. The cross-validated area under receiver operating characteristics curve (AUC) for the screening instrument was 0.80.ConclusionsEducational level is the single most important predictor for new-onset physical disability two months after ICU stay, followed by impaired core stability at ICU discharge, the presence of fractures and ICU stay longer than two days. A simple screening instrument based on these predictors can be used at ICU discharge to determine the risk for new-onset physical disability. This preliminary instrument may help clinicians to identify patients in need of support, but needs external validation prior to wider clinical use.

Pain rather than induced emotions and ICU sound increases skin conductance variability in healthy volunteers

Assessing pain in critically ill patients is difficult. Skin conductance variability (SCV), induced by the sympathetic response to pain, has been suggested as a method to identify pain in poorly communicating patients. However, SCV, a derivate of conventional skin conductance, could potentially also be sensitive to emotional stress. The purpose of the study was to investigate if pain and emotional stress can be distinguished with SCV.

Body image and psychological outcome after severe skin and soft tissue infection requiring intensive care.

Patients with severe skin and soft tissue infection (SSTI) requiring intensive care unit (ICU) stay are commonly treated with antibiotics, surgery and in some centers also with hyperbaric oxygen therapy. Long‐term follow‐up of body image and psychological outcome has not been described despite extensive surgery, potentially altered body image and subsequent psychological problems. The aim was to describe perceived body image and its relation to anxiety, depression and post‐traumatic stress disorder (PTSD)‐related symptoms in patients with severe SSTI 1 year after ICU stay. Specifically, we aimed to assess potential differences related to gender and anatomic site of infection.

Education level and health-related quality of life after oesophageal cancer surgery: a nationwide cohort study

Objective The purpose of the study was to investigate whether low education level was associated with patients’ health-related quality of life (HRQOL) after oesophageal cancer resection. Setting A nationwide cohort study in Sweden. Participants In total, 378 patients who underwent oesophageal cancer surgery in 2001–2005 were followed up 6 months and 3 years after surgery. Outcome measures HRQOL was assessed by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (QLQ-C30) and the oesophageal cancer-specific module. The association between level of education and HRQOL was calculated with linear regression models, providing mean score differences (MD) and 95% CIs. Data were analysed separately for women and men. Results Education level was not associated with HRQOL recovery after oesophageal cancer surgery. However, when data were stratified by sex, lower education was associated with worse emotional function (MD −13; 95% CI −22 to −3), more symptoms of insomnia (MD 20; 95% CI 8 to 32) and reflux (MD: 15; 95% CI 3 to 26) for women, but not for men. Among women, low education was in general associated with worse functioning and more symptoms. Conclusions Low education was not associated with worse HRQOL after oesophageal cancer surgery. However, when data were stratified for sex, low education level was associated with worse functioning and more symptoms in certain HRQOL domains for women, particularly in a short-term perspective. For men, no such association was found.

The relation between skin conductance responses and recovery from symptoms of PTSD

The purpose was to investigate if potentially stressful reminders of the intensive care unit (ICU) stay influenced variability in transient skin conductance responses, and whether such changes were associated with post‐traumatic stress symptoms (PTSS), and development of symptoms over time.