Cédric Bruel

Quality of life in patients aged 80 or over after ICU discharge

IntroductionOur objective was to describe self-sufficiency and quality of life one year after intensive care unit (ICU) discharge of patients aged 80 years or over.MethodsWe performed a prospective observational study in a medical-surgical ICU in a tertiary non-university hospital. We included patients aged 80 or over at ICU admission in 2005 or 2006 and we recorded age, admission diagnosis, intensity of care, and severity of acute and chronic illnesses, as well as ICU, hospital, and one-year mortality rates. Self-sufficiency (Katz Index of Activities of Daily Living) was assessed at ICU admission and one year after ICU discharge. Quality of life (WHO-QOL OLD and WHO-QOL BREF) was assessed one year after ICU discharge.ResultsOf the 115 consecutive patients aged 80 or over (18.2% of admitted patients), 106 were included. Mean age was 84 ± 3 years (range, 80 to 92). Mortality was 40/106 (37%) at ICU discharge, 48/106 (45.2%) at hospital discharge, and 73/106 (68.9%) one year after ICU discharge. In the 23 patients evaluated after one year, self-sufficiency was unchanged compared to the pre-admission status. Quality of life evaluations after one year showed that physical health, sensory abilities, self-sufficiency, and social participation had slightly worse ratings than the other domains, whereas social relationships, environment, and fear of death and dying had the best ratings. Compared to an age- and sex-matched sample of the general population, our cohort had better ratings for psychological health, social relationships, and environment, less fear of death and dying, better expectations about past, present, and future activities and better intimacy (friendship and love).ConclusionsAmong patients aged 80 or over who were selected at ICU admission, 80% were self-sufficient for activities of daily living one year after ICU discharge, 31% were alive, with no change in self-sufficiency and with similar quality of life to that of the general population matched on age and sex. However, these results must be interpreted cautiously due to the small sample of survivors.

Opinions of families, staff, and patients about family participation in care in intensive care units

PURPOSEnThe aims of the study were to assess opinions of caregivers, families, and patients about involvement of families in the care of intensive care unit (ICU) patients; to evaluate the prevalence of symptoms of anxiety and depression in family members; and to measure family satisfaction with care.nnnMATERIALS AND METHODSnBetween days 3 and 5, perceptions by families and ICU staff of family involvement in care were collected prospectively at a single center. Family members completed the Hospital Anxiety and Depression Scale (HADS) and a satisfaction scale (Critical Care Family Needs Inventory). Nurses recorded care provided spontaneously by families. Characteristics of patient-relative pairs (n = 101) and ICU staff (n = 45) were collected. Patients described their perceptions of family participation in care during a telephone interview, 206 ± 147 days after hospital discharge.nnnRESULTSnThe numbers of patient-relative pairs for whom ICU staff reported favorable perceptions were 101 (100%) of 101 for physicians, 91 (90%) for nurses, and 95 (94%) for nursing assistants. Only 4 (3.9%) of 101 families refused participation in care. Only 14 (13.8%) of 101 families provided care spontaneously. The HADS score showed symptoms of anxiety in 58 (58.5%) of 99 and of depression in 26 (26.2%) of 99 family members. The satisfaction score was high (11.0 ± 1.25). Among patients, 34 (77.2%) of 44 had a favorable perception of family participation in care.nnnCONCLUSIONSnFamilies and ICU staff were very supportive of family participation in care. Most patients were also favorable to care by family members.

A model to predict short-term death or readmission after intensive care unit discharge.

OBJECTIVEnEarly unplanned readmission to the intensive care unit (ICU) carries a poor prognosis, and post-ICU mortality may be related, in part, to premature ICU discharge. Our objectives were to identify independent risk factors for early post-ICU readmission or death and to construct a prediction model.nnnDESIGNnRetrospective analysis of a prospective database was done.nnnSETTINGnFour ICUs of the French Outcomerea network participated.nnnPATIENTSnPatients were consecutive adults with ICU stay longer than 24 hours who were discharged alive to same-hospital wards without treatment-limitation decisions.nnnMAIN RESULTSnOf 5014 admitted patients, 3462 met our inclusion criteria. Age was 60.6 ± 17.6 years, and admission Simplified Acute Physiology Score II (SAPS II) was 35.1 ± 15.1. The rate of death or ICU readmission within 7 days after ICU discharge was 3.0%. Independent risk factors for this outcome were age, SAPS II at ICU admission, use of a central venous catheter in the ICU, Sepsis-related Organ Failure Assessment and Systemic Inflammatory Response Syndrome scores before ICU discharge, and discharge at night. The predictive model based on these variables showed good calibration. Compared with SAPS II at admission or Stability and Workload Index for Transfer at discharge, discrimination was better with our model (area under receiver operating characteristics curve, 0.74; 95% confidence interval, 0.68-0.79).nnnCONCLUSIONnAmong patients without treatment-limitation decisions and discharged alive from the ICU, 3.0% died or were readmitted within 7 days. Independent risk factors were indicators of patients severity and discharge at night. Our prediction model should be evaluated in other ICU populations.

The ETHICA study (part I): elderly’s thoughts about intensive care unit admission for life-sustaining treatments

PurposeTo assess preferences among individuals aged ≥80 years for a future hypothetical critical illness requiring life-sustaining treatments.MethodsObservational cohort study of consecutive community-dwelling elderly individuals previously hospitalised in medical or surgical wards and of volunteers residing in nursing homes or assisted-living facilities. The participants were interviewed at their place of residence after viewing films of scenarios involving the use of non-invasive mechanical ventilation (NIV), invasive mechanical ventilation (IMV), and renal replacement therapy after a period of invasive mechanical ventilation (RRT after IMV). Demographic, clinical, and quality-of-life data were collected. Participants chose among four responses regarding life-sustaining treatments: consent, refusal, no opinion, and letting the physicians decide.ResultsThe sample size was 115 and the response rate 87xa0%. Mean participant age was 84.8xa0±xa03.5xa0years, 68xa0% were female, and 81xa0% and 71xa0% were independent for instrumental activities and activities of daily living, respectively. Refusal rates among the elderly were 27xa0% for NIV, 43xa0% for IMV, and 63xa0% for RRT (after IMV). Demographic characteristics associated with refusal were married status for NIV [relative risk (RR), 2.9; 95xa0% confidence interval (95xa0%CI), 1.5–5.8; pxa0=xa00.002] and female gender for IMV (RR, 2.4; 95xa0%CI, 1.2–4.5; pxa0=xa00.01) and RRT (after IMV) (RR, 2.7; 95xa0%CI, 1.4–5.2; pxa0=xa00.004). Quality of life was associated with choices regarding all three life-sustaining treatments.ConclusionsIndependent elderly individuals were rather reluctant to accept life-sustaining treatments, especially IMV and RRT (after IMV). Their quality of life was among the determinants of their choices.

Antithrombin supplementation for anticoagulation during continuous hemofiltration in critically ill patients with septic shock: a case-control study

IntroductionAcquired antithrombin III (AT) deficiency may induce heparin resistance and premature membrane clotting during continuous renal replacement therapy (CRRT). The purpose of this study was to evaluate the effect of AT supplementation on filter lifespan in critically ill patients with septic shock requiring CRRT.MethodsWe conducted a retrospective case-control analysis based on a 4-year observational study with prospectively collected data in two medical intensive care units in a university hospital. In all, 106 patients with septic shock underwent CRRT during the study period (55 during 2001 to 2002 and 51 during 2003 to 2004). Of these, 78 had acquired AT deficiency (plasma level below 70%) at onset of renal supportive therapy, 40 in the first 2-year period and 38 in the last 2-year period. In the latter intervention period, patients received AT supplementation (50 IU/kg) during CRRT each time that plasma AT activity, measured once daily, fell below 70%.ResultsIn a case-control analysis of the 78 patients with acquired AT deficiency, groups were similar for baseline characteristics, except in severity of illness as assessed by a higher Simplified Acute Physiology Score (SAPS) II after 2002. In comparison with controls, cases had a significantly greater AT level after AT supplementation, but not at baseline, and a smaller number of episodes of clots, without excess bleeding risk. The median hemofilter survival time was longer in the AT group than in the heparin group (44.5 versus 33.4 hours; p = 0.0045). The hemofiltration dose, assessed by the ratio of delivered to prescribed ultrafiltration, increased during intervention. AT supplementation was independently associated with a decrease in clotting rate, whereas femoral angioaccess and higher SAPS II were independent predictors of filter failure. However, mortality did not differ between periods, in the control period the observed mortality was significantly higher than predicted by the SAPS II score, unlike in the treatment period.ConclusionIn sepsis patients requiring CRRT and with acquired AT deficiency, anticoagulation with unfractionated heparin plus AT supplementation prevent premature filter clotting and may contribute to improving outcome, but the cost-effectiveness of AT remains to be determined.

The ETHICA study (part II): simulation study of determinants and variability of ICU physician decisions in patients aged 80 or over

PurposeTo assess physician decisions about ICU admission for life-sustaining treatments (LSTs).MethodsObservational simulation study of physician decisions for patients aged ≥80xa0years. Each patient was allocated at random to four physicians who made decisions based on actual bed availability and existence of an additional bed before and after obtaining information on patient preferences. The simulations involved non-invasive ventilation (NIV), invasive mechanical ventilation (IMV), and renal replacement therapy after a period of IMV (RRT after IMV).ResultsThe physician participation rate was 100/217 (46xa0%); males without religious beliefs predominated, and median ICU experience was 9xa0years. Among participants, 85.7, 78, and 62xa0% felt that NIV, IMV, or RRT (after IMV) was warranted, respectively. By logistic regression analysis, factors associated with admission were age <85xa0years, self-sufficiency, and bed availability for NIV and IMV. Factors associated with IMV were previous ICU stay (OR 0.29, 95xa0% CI 0.13–0.65, pxa0=xa00.01) and cancer (OR 0.23, 95xa0% CI 0.10–0.52, pxa0=xa00.003), and factors associated with RRT (after IMV) were living spouse (OR 2.03, 95xa0% CI 1.04–3.97, pxa0=xa00.038) and respiratory disease (OR 0.42, 95xa0% CI 0.23–0.76, pxa0=xa00.004). Agreement among physicians was low for all LSTs. Knowledge of patient preferences changed physician decisions for 39.9, 56, and 57xa0% of patients who disagreed with the initial physician decisions for NIV, IMV, and RRT (after IMV) respectively. An additional bed increased admissions for NIV and IMV by 38.6 and 13.6xa0%, respectively.ConclusionsPhysician decisions for elderly patients had low agreement and varied greatly with bed availability and knowledge of patient preferences.

Phenomenologic analysis of healthcare worker perceptions of intensive care unit diaries.

IntroductionStudies have reported associations between diaries kept for intensive care unit (ICU) patients and long-term quality-of-life and psychological outcomes in patients and their relatives. Little was known about perceptions of healthcare workers reading and writing in the diaries. We investigated healthcare worker perceptions the better to understand their opinions and responses to reading and writing in the diaries.MethodsWe used a phenomenologic approach to conduct a qualitative study of 36 semistructured interviews in a medical-surgical ICU in a 460-bed tertiary hospital.ResultsTwo domains of perception were assessed: reading and writing in the diaries. These two domains led to four main themes in the ICU workers perceptions: suffering of the families; using the diary as a source of information for families but also as generating difficulties in writing bad news; determining the optimal interpersonal distance with the patient and relatives; and using the diary as a tool for constructing a narrative of the patients ICU stay.ConclusionsThe ICU workers thought that the diary was beneficial in communicating the suffering of families while providing comfort and helping to build the patients ICU narrative. They reported strong emotions related to the diaries and a perception of intruding into the patients and families privacy when reading the diaries. Fear of strong emotional investment may adversely affect the ability of ICU workers to perform their duties optimally. ICU workers are in favor of ICU diaries, but activation by the diaries of emotions among younger ICU workers may require specific support.

Writing In and Reading ICU Diaries: Qualitative Study of Families' Experience in the ICU

Purpose Keeping an ICU patient diary has been reported to benefit the patients recovery. Here, we investigated the families experience with reading and writing in patient ICU diaries kept by both the family and the staff. Methods We conducted a qualitative study involving 32 semi-structured in-depth interviews of relatives of 26 patients (34% of all family members who visited patients) who met our ICU-diary criterion, i.e., ventilation for longer than 48 hours. Grounded theory was used to conceptualise the interview data via a three-step coding process (open coding, axial coding, and selective coding). Results Communicative, emotional, and humanising experiences emerged from our data. First, family members used the diaries to access, understand, and assimilate the medical information written in the diaries by staff members, and then to share this information with other family members. Second, the diaries enabled family members to maintain a connection with the patient by documenting their presence and expressing their love and affection. Additionally, families confided in the diaries to maintain hope. Finally, family members felt the diaries humanized the medical staff and patient. Conclusions Our findings indicate positive effects of diaries on family members. The diaries served as a powerful tool to deliver holistic patient- and family-centered care despite the potentially dehumanising ICU environment. The diaries made the family members aware of their valuable role in caring for the patient and enhanced their access to and comprehension of medical information. Diaries may play a major role in improving the well-being of ICU-patient families.

A case of daptomycin-induced immune thrombocytopenia

ABSTRACT We report a case of severe daptomycin-induced immune thrombocytopenia in a patient treated for methicillin-resistant Staphylococcus epidermidis and ampicillin-resistant Enterococcus faecalis bacteremia acquired in an intensive care unit. Serum antibodies bound to platelets in the presence of daptomycin on flow cytometry. There was no evidence of other causes of thrombocytopenia. The patient died of brain herniation complicating extensive cerebral hemorrhage. To our knowledge, this is the first described case of daptomycin-induced thrombocytopenia.