Dave A. Dongelmans

Poor functional status immediately after discharge from an intensive care unit

Purpose. To evaluate the functional status of patients within the first week of discharge from an intensive care unit (ICU), and to identify predictors and explanatory factors of functional status. Methods. A prospective, observational, cohort study was conducted with consecutive ICU patients who had stayed in a mixed, closed-format, university-level ICU for longer than 48 h. Results. Between 3 and 7 days of discharge from the ICU, functional status (as primary outcome), walking ability, muscle strength, and sensory and cognitive functioning were assessed in 69 survivors. The overall functional status was poor (median Barthel Index 6). In their ability to perform basic activities of daily living, 67% percent were severely dependent, 15% were moderately dependent, and 9% were slightly dependent on other people. Independent walking was impossible for 73% of participants, grip strength was reduced for 50%, and 30% had cognitive impairments. Duration of ventilation was associated with functional status after ICU discharge. Reduced grip strength and walking ability were identified as explanatory factors for poorer functional status shortly after discharge from the ICU. Conclusion. In the first week after discharge from the ICU, the majority of the patients had substantial functional disabilities in activities of daily living. These disabilities were more severe in patients who experienced ventilation for a longer period of time. There is a need for prospective studies focusing on functional recovery to support informed decision-making concerning the care of critically ill patients after ICU discharge.

FUNCTIONAL STATUS AFTER INTENSIVE CARE: A CHALLENGE FOR REHABILITATION PROFESSIONALS TO IMPROVE OUTCOME

OBJECTIVE To examine restrictions in daily functioning from a rehabilitation perspective in patients one year after discharge from the intensive care unit, and to identify prognostic factors for functional status. DESIGN Cross-sectional design. PATIENTS Consecutive patients who were admitted to the intensive care unit for more than 48 h (n = 255). METHODS One year after intensive care, functional status (Sickness Impact Profile) as primary outcome, and Quality of Life (SF-36), anxiety and depression (Hospital Anxiety Depression Scale), and post-traumatic stress disorder (Impact of Events Scale) were evaluated. RESULTS Fifty-four percent of the patients had restrictions in daily functioning. Walking and social activities were most frequently restricted (30-60% of the patients). Quality of life was lower than the general Dutch population. Symptoms of anxiety and depression were found in 14%, and post-traumatic stress disorder in 18%. Severity of illness at admission and length of stay in the intensive care unit were identified as prognostic factors, although they explained only 10% of functional status. CONCLUSION The high prevalence of long-lasting restrictions in physical, social and psychological functioning among patients who stayed in the intensive care unit for at least 2 days implies that these patients are a potential target population for rehabilitation medicine. Multidisciplinary therapies need to be developed and evaluated in order to improve outcome.

POOR FUNCTIONAL RECOVERY AFTER A CRITICAL ILLNESS: A LONGITUDINAL STUDY

OBJECTIVE To determine the time course of functional health status, and to inventory impairments in body functions, limitations in activities, and restrictions in participation after critical illness. DESIGN Prospective observational cohort study. SETTING Mixed medical and surgical closed format; intensive care unit of an academic medical hospital. PATIENTS Consecutive patients over a period of 3 months who were ventilated in the intensive care unit for more than 48 h (n = 116). METHODS Functional health status was assessed 3, 6 and 12 months after discharge from the intensive care unit using the Sickness Impact Profile 68. Impairments in function, limitations in activities, and restrictions in participation, classified according to the International Classification of Functioning, Disability, and Health (ICF), were evaluated after 3 and 12 months. RESULTS Due to a high mortality rate (48%) and poor health conditions, data could not be obtained from all participants at all measurement points. Physical functioning and social behaviour improved predominantly within the first 6 months, while impaired psychological functioning remained unchanged within one year after discharge from the intensive care unit. After one year, 69% of patients were still restricted in performing daily activities and only 50% had resumed work. CONCLUSION The extent and severity of lasting intensive care unit-related disability necessitates the development of multidisciplinary after-care to improve health status, functional independence and return to work.

Frequency and nature of drug-drug interactions in the intensive care unit

Drug‐drug interactions (DDIs) may compromise patient safety. However, there are no good estimates of their frequency or understanding of their nature in the intensive care unit (ICU). The objective of this study was to determine the frequency and nature of potential DDIs (pDDIs) in the ICU when assessed in light of documented and perceived clinical relevance.

A usability evaluation of a SNOMED CT based compositional interface terminology for intensive care

OBJECTIVE To evaluate the usability of a large compositional interface terminology based on SNOMED CT and the terminology application for registration of the reasons for intensive care admission in a Patient Data Management System. DESIGN Observational study with user-based usability evaluations before and 3 months after the system was implemented and routinely used. MEASUREMENTS Usability was defined by five aspects: effectiveness, efficiency, learnability, overall user satisfaction, and experienced usability problems. Qualitative (the Think-Aloud user testing method) and quantitative (the System Usability Scale questionnaire and Time-on-Task analyses) methods were used to examine these usability aspects. RESULTS The results of the evaluation study revealed that the usability of the interface terminology fell short (SUS scores before and after implementation of 47.2 out of 100 and 37.5 respectively out of 100). The qualitative measurements revealed a high number (n=35) of distinct usability problems, leading to ineffective and inefficient registration of reasons for admission. The effectiveness and efficiency of the system did not change over time. About 14% (n=5) of the revealed usability problems were related to the terminology content based on SNOMED CT, while the remaining 86% (n=30) was related to the terminology application. The problems related to the terminology content were more severe than the problems related to the terminology application. CONCLUSIONS This study provides a detailed insight into how clinicians interact with a controlled compositional terminology through a terminology application. The extensiveness, complexity of the hierarchy, and the language usage of an interface terminology are defining for its usability. Carefully crafted domain-specific subsets and a well-designed terminology application are needed to facilitate the use of a complex compositional interface terminology based on SNOMED CT.

Tracheotomy does not affect reducing sedation requirements of patients in intensive care – a retrospective study

IntroductionTranslaryngeal intubated and ventilated patients often need sedation to treat anxiety, agitation and/or pain. Current opinion is that tracheotomy reduces sedation requirements. We determined sedation needs before and after tracheotomy of intubated and mechanically ventilated patients.MethodsWe performed a retrospective analysis of the use of morphine, midazolam and propofol in patients before and after tracheotomy.ResultsOf 1,788 patients admitted to our intensive care unit during the study period, 129 (7%) were tracheotomized. After the exclusion of patients who received a tracheotomy before or at the day of admittance, 117 patients were left for analysis. The daily dose (DD; the amount of sedatives for each day) divided by the mean daily dose (MDD; the mean amount of sedatives per day for the study period) in the week before and the week after tracheotomy was 1.07 ± 0.93 DD/MDD versus 0.30 ± 0.65 for morphine, 0.84 ± 1.03 versus 0.11 ± 0.46 for midazolam, and 0.62 ± 1.05 versus 0.15 ± 0.45 for propofol (p < 0.01). However, when we focused on a shorter time interval (two days before and after tracheotomy), there were no differences in prescribed doses of morphine and midazolam. Studying the course in DD/MDD from seven days before the placement of tracheotomy, we found a significant decline in dosage. From day -7 to day -1, morphine dosage (DD/MDD) declined by 3.34 (95% confidence interval -1.61 to -6.24), midazolam dosage by 2.95 (-1.49 to -5.29) and propofol dosage by 1.05 (-0.41 to -2.01). After tracheotomy, no further decrease in DD/MDD was observed and the dosage remained stable for all sedatives. Patients in the non-surgical and acute surgical groups received higher dosages of midazolam than patients in the elective surgical group. Time until tracheotomy did not influence sedation requirements. In addition, there was no significant difference in sedation between different patient groups.ConclusionIn our intensive care unit, sedation requirements were not further reduced after tracheotomy. Sedation requirements were already sharply declining before tracheotomy was performed.

Data Resource Profile: the Dutch National Intensive Care Evaluation (NICE) Registry of Admissions to Adult Intensive Care Units

Data Resource Profile: the Dutch National Intensive Care Evaluation (NICE) Registry of Admissions to Adult Intensive Care Units Nick van de Klundert, Rebecca Holman,* Dave A. Dongelmans and Nicolette F. de Keizer National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands, Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands, Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands

Adaptive support ventilation with protocolized de-escalation and escalation does not accelerate tracheal extubation of patients after nonfast-track cardiothoracic surgery.

BACKGROUND:It is uncertain whether adaptive support ventilation (ASV) accelerates weaning of nonfast-track cardiothoracic surgery patients. A lower operator set %-minute ventilation with ASV may allow for an earlier definite switch from controlled to assisted ventilation, potentially hastening tracheal extubation. We hypothesized that ASV using protocolized de-escalation and escalation of operator set %-minute ventilation (ASV-DE) reduces time until tracheal extubation compared with ASV using a fixed operator set %-minute ventilation (standard ASV) in uncomplicated patients after nonfast-track coronary artery bypass graft. METHODS:We performed a randomized controlled trial comparing ASV-DE with standard ASV. With ASV-DE, as soon as body temperature was >35.0°C with pH >7.25, operator set %-minute ventilation was decreased stepwise to a minimum of 70%. RESULTS:Sixty-three patients were randomized to ASV-DE, and 63 patients to standard ASV. The duration of mechanical ventilation was not different between groups (10.8 [6.5–16.1] vs 10.7 [6.6–13.9] hours, ASV-DE versus standard ASV; P = 0.32). Time until the first assisted breathing period was shorter (3.1 [2.0–6.7] vs 3.9 [2.1–7.5] hours) and the number of assisted ventilation episodes was higher (78 [34–176] vs 57 [32–116] episodes), but differences did not reach statistical significance. The duration of assisted ventilation episodes that ended with tracheal extubation was different between groups (2.5 [0.9–4.6] vs 1.4 [0.3–3.5] hours, ASV-DE versus standard ASV; P < 0.05). CONCLUSION:Compared with standard ASV, weaning of patients after nonfast-track coronary artery bypass graft using ASV with protocolized de-escalation and escalation does not shorten time to tracheal extubation.

Determinants of Tidal Volumes with Adaptive Support Ventilation : A Multicenter Observational Study

INTRODUCTION:In the present study, we investigated the behavior of adaptive support ventilation (ASV) in patients after cardiothoracic surgery. We determined tidal volumes (Vt) and factors that influence Vt with this mode of microprocessor-controlled mechanical ventilation (MV). METHODS:This was a prospective, multicenter, observational study in three Dutch intensive care units over a 5-mo period. MV data were collected during steady-state after arrival in the intensive care unit. RESULTS:Data were collected for 346 consecutive patients after cardiothoracic surgery: 262 patients weaned with ASV, and 84 patients weaned with pressure-controlled/pressure-support MV. With ASV the mean (± sd) Vt expressed per kilogram actual body weight was 7.1 ± 1.6 mL. Expressed per kilogram ideal body weight (IBW), Vt was 8.3 ± 1.5 mL. In patients with a correctly set body weight (SBW) (i.e., the IBW), Vt was 8.1 ± 1.4 mL/kg. With pressure-controlled/pressure-support-MV Vt was 7.3 ± 1.4 mL/kg IBW (P < 0.001 vs ASV). Multivariate logistic regression analysis showed Vt with ASV to be dependent on only two parameters: respiratory rate and the correctness of SBW. CONCLUSIONS:Vt with ASV seems to be dependent on two parameters: respiratory rate and the correctness of SBW. The first factor is not clinically important because respiratory rate is automatically chosen by the microprocessor. The second factor is clinically important because it is the only factor that can be influenced by the operator. Our data show the importance of setting the correct weight with ASV. With ASV, Vt are >8 mL/kg IBW in a substantial number of patients. Randomized clinical trials should be performed to compare ASV with other ventilation modes.

Adaptive Support Ventilation May Deliver Unwanted Respiratory Rate–Tidal Volume Combinations in Patients with Acute Lung Injury Ventilated According to an Open Lung Concept

BACKGROUND With adaptive support ventilation, respiratory rate and tidal volume (V(T)) are a function of the Otis least work of breathing formula. We hypothesized that adaptive support ventilation in an open lung ventilator strategy would deliver higher V(T)s to patients with acute lung injury. METHODS Patients with acute lung injury were ventilated according to a local guideline advising the use of lower V(T) (6-8 ml/kg predicted body weight), high concentrations of positive end-expiratory pressure, and recruitment maneuvers. Ventilation parameters were recorded when the ventilator was switched to adaptive support ventilation, and after recruitment maneuvers. If V(T) increased more than 8 ml/kg predicted body weight, airway pressure was limited to correct for the rise of V(T). RESULTS Ten patients with a mean (±SD) Pao(2)/Fio(2) of 171 ± 86 mmHg were included. After a switch from pressure-controlled ventilation to adaptive support ventilation, respiratory rate declined (from 31 ± 5 to 21 ± 6 breaths/min; difference = 10 breaths/min, 95% CI 3-17 breaths/min, P = 0.008) and V(T) increased (from 6.5 ± 0.8 to 9.0 ± 1.6 ml/kg predicted body weight; difference = 2.5 ml, 95% CI 0.4-4.6 ml/kg predicted body weight, P = 0.02). Pressure limitation corrected for the rise of V(T), but minute ventilation declined, forcing the user to switch back to pressure-controlled ventilation. CONCLUSIONS Adaptive support ventilation, compared with pressure-controlled ventilation in an open lung strategy setting, delivers a lower respiratory rate-higher V(T) combination. Pressure limitation does correct for the rise of V(T), but leads to a decline in minute ventilation.