Craig R. Weinert

Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference.

Background: Millions of patients are discharged from intensive care units annually. These intensive care survivors and their families frequently report a wide range of impairments in their health status which may last for months and years after hospital discharge. Objectives: To report on a 2-day Society of Critical Care Medicine conference aimed at improving the long-term outcomes after critical illness for patients and their families. Participants: Thirty-one invited stakeholders participated in the conference. Stakeholders represented key professional organizations and groups, predominantly from North America, which are involved in the care of intensive care survivors after hospital discharge. Design: Invited experts and Society of Critical Care Medicine members presented a summary of existing data regarding the potential long-term physical, cognitive and mental health problems after intensive care and the results from studies of postintensive care unit interventions to address these problems. Stakeholders provided reactions, perspectives, concerns and strategies aimed at improving care and mitigating these long-term health problems. Measurements and Main Results: Three major themes emerged from the conference regarding: (1) raising awareness and education, (2) understanding and addressing barriers to practice, and (3) identifying research gaps and resources. Postintensive care syndrome was agreed upon as the recommended term to describe new or worsening problems in physical, cognitive, or mental health status arising after a critical illness and persisting beyond acute care hospitalization. The term could be applied to either a survivor or family member. Conclusions: Improving care for intensive care survivors and their families requires collaboration between practitioners and researchers in both the inpatient and outpatient settings. Strategies were developed to address the major themes arising from the conference to improve outcomes for survivors and families.

Intensive care unit drug use and subsequent quality of life in acute lung injury patients

ObjectiveTo examine the relationship between the use of sedative and neuromuscular blocking agents during a patient’s intensive care unit (ICU) stay and subsequent measures of health-related quality of life. DesignCross-sectional mail survey and retrospective medical record abstraction of a prospectively identified cohort of lung injury patients. SettingICUs in three teaching hospitals in a major metropolitan area. PatientsPatients with acute lung injury (n = 24). InterventionsNone—observational study. Measurements and Main ResultsPatients’ charts were reviewed for those patients returning postdischarge quality-of-life questionnaires. Duration, daily dose, and route of administration for sedatives and neuromuscular blocking agents were abstracted from ICU flow sheets. Relationships among ICU variables (days of sedation, days of neuromuscular blockade, and severity of illness as measured by Acute Physiology and Chronic Health Evaluation III score) and outcomes (symptoms of depression and symptoms of posttraumatic stress disorder) were assessed. Depressive symptoms at follow-up were correlated with days of sedation (p = .007), but not with days of neuromuscular blockade or initial severity of illness. The composite posttraumatic stress disorder symptom impact score was correlated with days of sedation (p = .006) and days of neuromuscular blockade (p = .035), but not with initial severity of illness. There were no significant differences between the frequency of patients reporting a specific posttraumatic stress disorder symptom in the high sedation group and the low sedation group, and there were no significant differences in specific posttraumatic stress disorder symptoms between the group that had received neuromuscular blockade and those who had not. ConclusionsThe use of sedatives and neuromuscular blocking agents in the ICU is positively associated with subsequent measures of depression and posttraumatic stress disorder symptoms 6–41 months after ICU treatment for acute lung injury.

Targeted temperature management in critical care: A report and recommendations from five professional societies*

Objective:Representatives of five international critical care societies convened topic specialists and a nonexpert jury to review, assess, and report on studies of targeted temperature management and to provide clinical recommendations. Data Sources:Questions were allocated to experts who reviewed their areas, made formal presentations, and responded to questions. Jurors also performed independent searches. Sources used for consensus derived exclusively from peer-reviewed reports of human and animal studies. Study Selection:Question-specific studies were selected from literature searches; jurors independently determined the relevance of each study included in the synthesis. Conclusions and Recommendations:1) The jury opines that the term “targeted temperature management” replace “therapeutic hypothermia.” 2) The jury opines that descriptors (e.g., “mild”) be replaced with explicit targeted temperature management profiles. 3) The jury opines that each report of a targeted temperature management trial enumerate the physiologic effects anticipated by the investigators and actually observed and/or measured in subjects in each arm of the trial as a strategy for increasing knowledge of the dose/duration/response characteristics of temperature management. This enumeration should be kept separate from the body of the report, be organized by body systems, and be made without assertions about the impact of any specific effect on the clinical outcome. 4) The jury STRONGLY RECOMMENDS targeted temperature management to a target of 32°C–34°C as the preferred treatment (vs. unstructured temperature management) of out-of-hospital adult cardiac arrest victims with a first registered electrocardiography rhythm of ventricular fibrillation or pulseless ventricular tachycardia and still unconscious after restoration of spontaneous circulation (strong recommendation, moderate quality of evidence). 5) The jury WEAKLY RECOMMENDS the use of targeted temperature management to 33°C–35.5°C (vs. less structured management) in the treatment of term newborns who sustained asphyxia and exhibit acidosis and/or encephalopathy (weak recommendation, moderate quality of evidence).

Effects of Patient-Directed Music Intervention on Anxiety and Sedative Exposure in Critically Ill Patients Receiving Mechanical Ventilatory Support: A Randomized Clinical Trial

IMPORTANCE Alternatives to sedative medications, such as music, may alleviate the anxiety associated with ventilatory support. OBJECTIVE To test whether listening to self-initiated patient-directed music (PDM) can reduce anxiety and sedative exposure during ventilatory support in critically ill patients. DESIGN, SETTING, AND PATIENTS Randomized clinical trial that enrolled 373 patients from 12 intensive care units (ICUs) at 5 hospitals in the Minneapolis-St Paul, Minnesota, area receiving acute mechanical ventilatory support for respiratory failure between September 2006 and March 2011. Of the patients included in the study, 86% were white, 52% were female, and the mean (SD) age was 59 (14) years. The patients had a mean (SD) Acute Physiology, Age and Chronic Health Evaluation III score of 63 (21.6) and a mean (SD) of 5.7 (6.4) study days. INTERVENTIONS Self-initiated PDM (n = 126) with preferred selections tailored by a music therapist whenever desired while receiving ventilatory support, self-initiated use of noise-canceling headphones (NCH; n = 122), or usual care (n = 125). MAIN OUTCOMES AND MEASURES Daily assessments of anxiety (on 100-mm visual analog scale) and 2 aggregate measures of sedative exposure (intensity and frequency). RESULTS Patients in the PDM group listened to music for a mean (SD) of 79.8 (126) (median [range], 12 [0-796]) minutes/day. Patients in the NCH group wore the noise-abating headphones for a mean (SD) of 34.0 (89.6) (median [range], 0 [0-916]) minutes/day. The mixed-models analysis showed that at any time point, patients in the PDM group had an anxiety score that was 19.5 points lower (95% CI, -32.2 to -6.8) than patients in the usual care group (P = .003). By the fifth study day, anxiety was reduced by 36.5% in PDM patients. The treatment × time interaction showed that PDM significantly reduced both measures of sedative exposure. Compared with usual care, the PDM group had reduced sedation intensity by -0.18 (95% CI, -0.36 to -0.004) points/day (P = .05) and had reduced frequency by -0.21 (95% CI, -0.37 to -0.05) points/day (P = .01). The PDM group had reduced sedation frequency by -0.18 (95% CI, -0.36 to -0.004) points/day vs the NCH group (P = .04). By the fifth study day, the PDM patients received 2 fewer sedative doses (reduction of 38%) and had a reduction of 36% in sedation intensity. CONCLUSIONS AND RELEVANCE Among ICU patients receiving acute ventilatory support for respiratory failure, PDM resulted in greater reduction in anxiety compared with usual care, but not compared with NCH. Concurrently, PDM resulted in greater reduction in sedation frequency compared with usual care or NCH, and greater reduction in sedation intensity compared with usual care, but not compared with NCH. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00440700.

Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting.

Background:Increasing numbers of survivors of critical illness are at risk for physical, cognitive, and/or mental health impairments that may persist for months or years after hospital discharge. The post–intensive care syndrome framework encompassing these multidimensional morbidities was developed at the 2010 Society of Critical Care Medicine conference on improving long-term outcomes after critical illness for survivors and their families. Objectives:To report on engagement with non–critical care providers and survivors during the 2012 Society of Critical Care Medicine post–intensive care syndrome stakeholder conference. Task groups developed strategies and resources required for raising awareness and education, understanding and addressing barriers to clinical practice, and identifying research gaps and resources, aimed at improving patient and family outcomes. Participants:Representatives from 21 professional associations or health systems involved in the provision of both critical care and rehabilitation of ICU survivors in the United States and ICU survivors and family members. Design:Stakeholder consensus meeting. Researchers presented summaries on morbidities for survivors and their families, whereas survivors presented their own experiences. Meeting Outcomes:Future steps were planned regarding 1) recognizing, preventing, and treating post–intensive care syndrome, 2) building strategies for institutional capacity to support and partner with survivors and families, and 3) understanding and addressing barriers to practice. There was recognition of the need for systematic and frequent assessment for post–intensive care syndrome across the continuum of care, including explicit “functional reconciliation” (assessing gaps between a patient’s pre-ICU and current functional ability at all intra- and interinstitutional transitions of care). Future post–intensive care syndrome research topic areas were identified across the continuum of recovery: characterization of at-risk patients (including recognizing risk factors, mechanisms of injury, and optimal screening instruments), prevention and treatment interventions, and outcomes research for patients and families. Conclusions:Raising awareness of post–intensive care syndrome for the public and both critical care and non–critical care clinicians will inform a more coordinated approach to treatment and support during recovery after critical illness. Continued conceptual development and engagement with additional stakeholders is required.

Dexmedetomidine as adjunct treatment for severe alcohol withdrawal in the ICU

BackgroundPatients undergoing alcohol withdrawal in the intensive care unit (ICU) often require escalating doses of benzodiazepines and not uncommonly require intubation and mechanical ventilation for airway protection. This may lead to complications and prolonged ICU stays. Experimental studies and single case reports suggest the α2-agonist dexmedetomidine is effective in managing the autonomic symptoms seen with alcohol withdrawal. We report a retrospective analysis of 20 ICU patients treated with dexmedetomidine for benzodiazepine-refractory alcohol withdrawal.MethodsRecords from a 23-bed mixed medical-surgical ICU were abstracted from November 2008 to November 2010 for patients who received dexmedetomidine for alcohol withdrawal. The main analysis compared alcohol withdrawal severity scores and medication doses for 24 h before dexmedetomidine therapy with values during the first 24 h of dexmedetomidine therapy.ResultsThere was a 61.5% reduction in benzodiazepine dosing after initiation of dexmedetomidine (n = 17; p < 0. 001) and a 21.1% reduction in alcohol withdrawal severity score (n = 11; p = .015). Patients experienced less tachycardia and systolic hypertension following dexmedetomidine initiation. One patient out of 20 required intubation. A serious adverse effect occurred in one patient, in whom dexmedetomidine was discontinued for two 9-second asystolic pauses noted on telemetry.ConclusionsThis observational study suggests that dexmedetomidine therapy for severe alcohol withdrawal is associated with substantially reduced benzodiazepine dosing, a decrease in alcohol withdrawal scoring and blunted hyperadrenergic cardiovascular response to ethanol abstinence. In this series, there was a low rate of mechanical ventilation associated with the above strategy. One of 20 patients suffered two 9-second asystolic pauses, which did not recur after dexmedetomidine discontinuation. Prospective trials are warranted to compare adjunct treatment with dexmedetomidine versus standard benzodiazepine therapy.

The science of implementation: changing the practice of critical care.

Purpose of reviewFew would disagree that evidence from clinical research should be brought to the bedside in an efficient and equitable manner. Unfortunately, this common agreement does not result in practice change at the bedside where delayed and variable implementation is common. Recognition of this gap has resulted in a new discipline called implementation science that seeks to understand the reasons for slow adoption of clinical therapeutics and to discover effective strategies that accelerate practice change. This article reviews implementation theory and strategies and their effectiveness and relevance to critical care. Recent findingsThe absence of a proven effective framework for implementing clinical practice change has resulted in a patchwork of interventions in ambulatory and acute care medicine. There is an increasing appreciation that interventions should be undertaken only after careful, theory-based examination of the source and strength of the evidence, the organizational and professional context in which the change will be made, and the availability of facilitating methods. Barriers to implementing sepsis management programs have been identified and, in some cases, overcome. SummaryChanging clinical practice is sometimes as difficult as the basic science and clinical trials work that led to the discovery of beneficial therapies. Investigators are now beginning to develop and test more theory-based implementation models that are relevant to the clinical environment. A proportion of the resources used in developing an ICU guideline or protocol must be dedicated to the implementation strategy for successful adoption. ICUs are ideal organizations to test new approaches in implementation science. Intensive care professionals should insist that their practice environment have both a culture that is supportive of adopting new practices and adequate resources to implement them into patient care.

Development of a shortened state anxiety scale from the Spielberger State-Trait Anxiety Inventory (STAI) for patients receiving mechanical ventilatory support

Anxiety is a common experience for mechanically ventilated patients. There are a number of established instruments available to measure anxiety. However, there are significant limitations with these instruments, particularly the length of many scales when using them with ill persons. An instrument development study was conducted to develop a shortened scale from the 20-item Spielberger State Anxiety Inventory. Two-hundred ventilated patients were recruited from nine ICUs in the urban Midwest. Exploratory factor analysis techniques were used to create a shortened, 6-item scale, which accounted for 66.6 percent of the variance. A Cronbach’s alpha of 0.78 with a correlation of 0.92 to the 20-item version resulted based on a 6-item scale, and the shortened scale retained many of the desirable properties of the full-length version. The shortened version of the Spielberger State Anxiety Inventory generally had good psychometric properties. However, additional research is needed to further validate this shortened scale.

Relationship Between Persistence of Abdominal Symptoms and Successful Outcome After Cholecystectomy

BACKGROUND Patients frequently have persistent abdominal symptoms after undergoing cholecystectomy. The relationship between abdominal symptoms and biliary dysfunction is often unclear. OBJECTIVES To describe the persistence rate of abdominal symptoms in a large cohort of patients after elective cholecystectomy, to identify predictors of symptom persistence and operative success, to understand which symptoms improve after cholecystectomy, and to describe the important determinants of an unsuccessful operation. METHODS Secondary analysis of a prospective, multisite cohort study of 2481 patients undergoing elective cholecystectomy. RESULTS The mean +/- SD number of abdominal symptoms per patient decreased from 3.1 +/- 2.0 to 1.1 +/- 1.3; 27% of patients who identified a symptom as most bothersome before surgery still had the symptom 6 months after surgery. Symptom persistence rates ranged from 5.6% (vomiting) to 40.2% (gas/flatulence). A balance score that quantified the abdominal symptom mix between dyspeptic and biliary symptoms shifted after surgery to the dyspeptic category. Predictors of persistence of a most bothersome symptom were dyspeptic symptom category, worse operative risk and self-rated health status, symptom duration longer than 6 months, and no previous episodes of acute cholecystitis. The major correlate of not achieving a very successful outcome (15.2% of patients) was the presence of postoperative abdominal pain. Other predictors included worse self-rated health status and physical functioning, symptom duration longer than 6 months before surgery, and no previous episodes of acute cholecystitis. CONCLUSIONS Symptoms categorized as dyspeptic were more likely to persist than were biliary symptoms, although all symptoms showed a decrease in prevalence after cholecystectomy. More attention to the rationale for gallbladder removal and clarification of patient expectations for symptom relief might be necessary to improve outcomes after elective cholecystectomy.

Measurement of bleeding severity: a critical review

emostasis may be defined as the physiologic response to vascular injury. Bleeding may result from the failure of hemostatic mechanisms, sometimes aggravated by other pathologic processes. The need to control bleeding combined with the desire to minimize exposure to blood products has led to a recent interest in expanding the available armamentarium of hemostatic strategies. The accurate assessment of the usual primary endpoint (improvement or cessation of bleeding) is of critical importance in clinical trials of hemostatic strategies. In the setting of complex and sometimes expensive therapeutic options, it is important to select measures that are reliable, sensitive to changes in bleeding, of proven clinically validity, and easy to use. Apart from their utility in clinical trials, bleeding scales may be used to assess surgical or resuscitative interventions, to estimate the impact of underlying disease, or to assess the toxicity of therapies such as anticoagulation or cancer chemotherapy.