J D Young

The prevalence of post traumatic stress disorder in survivors of ICU treatment: a systematic review

ObjectiveTo determine the prevalence of post traumatic stress disorder in survivors of intensive care treatment.DesignSystematic literature review including Medline, Embase, CINAHL, PsycINFO and references from identified papers.Study selectionStudies determining the prevalence of PTSD in adult patients who had at least 24u202fh treatment on an intensive care unit. Independent duplicate data extraction. Study quality was evaluated in terms of study design and method and timing of PTSD assessment.Data synthesis and resultsOf the 1472 citations identified, 30 studies meeting the selection criteria were reviewed. PTSD was diagnosed by standardised clinical interview alone in 2 studies. Axa0self-report measure alone was used in 19 studies to measure PTSD symptomatology. The remaining 9 studies applied both standardised clinical interview and axa0self-report measure. The reported prevalence of PTSD was 0–64% when diagnosed by standardised clinical interview and 5–64% by self-report measure. PTSD assessments occurred 7 days to 8 years after intensive care discharge.ConclusionThe true prevalence of PTSD and the optimum timing and method of PTSD assessment have not yet been determined in intensive care unit survivors. Deficiencies in design, methodology and reporting make interpretation and comparison of quoted prevalence rates difficult, and rigorous longitudinal studies are needed.

A national survey of intensive care follow-up clinics

Intensive care follow‐up clinics allow extended review of survivors of critical illness. However, the current provision of intensive care follow‐up clinics in the UK is unknown. We performed a survey of intensive care follow‐up clinic practice in the UK. A questionnaire was sent to 298 intensive care units in the UK to determine the number of follow‐up clinics and details of current follow‐up practice. Responses were received from 266 intensive care units, an 89% response rate. Eighty units (30%) ran a follow‐up clinic. Only 47 (59%) of these clinics were funded. Of those intensive care units without a follow‐up clinic, 158 (88%) cited ‘financial constraints’ as the reason. Over half of the follow‐up clinics (44 clinics, 55%) were nurse‐led, and the majority (56 clinics, 77%) only routinely review patients treated on the intensive care unit for 3 or 4u2003days or longer. Nearly half of the follow‐up clinics (39 clinics, 49%) have pre‐negotiated access to at least one other out‐patient service.

A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients.

We conducted a randomised controlled trial of mandated five‐channel physiological monitoring vs standard care, in acute medical and surgical wards in a single UK teaching hospital. In all, 402 high‐risk medical and surgical patients were studied. The primary outcome was the proportion of patients experiencing one or more major adverse events, including urgent staff calls, changes to higher care levels, cardiac arrests or death, in 96u2003h following randomisation. Secondary outcomes were the proportion of patients requiring acute treatment changes, and the 30‐day and hospital mortality. In the 96u2003h following randomisation, 113 (56%) patients in the monitored arm and 116 (58%) in the control arm (OR 0.94, 95% CI 0.63–1.40, pu2003=u20030.76) had a major event. An acute change in treatment was necessary in 107 (53%) monitored patients and 101 (50%) control patients (OR 0.55, 95% CI 0.87–1.29). Thirty‐four (17%) monitored patients and 35 (17%) control patients died within 30u2003days. Thirteen patients in the control group received full five‐channel monitoring at the request of the ward staff. We conclude that mandated electronic vital signs monitoring in high risk medical and surgical patients has no effect on adverse events or mortality.

Epinephrine, norepinephrine, dobutamine, and dopexamine effects on free flap skin blood flow.

Background: The optimal sympathomimetic drug to support blood pressure without adverse vasoconstriction of free flap circulation remains unknown. This study examined the effects of four agents (epinephrine, norepinephrine, dobutamine, and dopexamine) on free flaps following resection of head and neck cancer. Methods: Twenty-four patients (25 data sets) were recruited into the study. Each patient received an infusion of the four drugs in a random order, with an intervening washout period between drugs, at four infusion rates. Continuous free flap skin blood flow monitoring was performed using laser Doppler velocimetry, with a second sensor on normal skin acting as a control. Global cardiovascular variables were monitored using the LiDCO Rapid Pulse Contour Analysis System (LiDCO Ltd., Cambridge, United Kingdom). Results: Dose-dependent, increased free flap skin blood flow was observed with norepinephrine and dobutamine. Both dopexamine and epinephrine infusions decreased blood flow. Flap skin blood conductance decreased (vasoconstriction) with norepinephrine, but markedly less than in control tissue, so overall the flap skin blood flow increased with increasing arterial blood pressure. Dobutamine increased flap skin conductance, without significantly increasing blood pressure, and modestly increased flap blood flow. Conclusions: Both dobutamine and norepinephrine had beneficial effects on flap skin blood flow. The maximal improvement in flow occurred with norepinephrine, making it the optimal pressor to use in patients with hypotension after free flap surgery.

A comparison of the laryngeal mask airway with the facemask and oropharyngeal airway for manual ventilation by first responders in children

In adults, first responders to a cardiopulmonary arrest provide better ventilation using a laryngeal mask airway than a facemask. It is unclear if the same is true in children. We investigated this by comparing the ability of 36 paediatric ward nurses to ventilate the lungs of 99 anaesthetised children (a model for cardiopulmonary arrest) using a laryngeal mask airway and using a facemask with an oropharyngeal airway. Anteroposterior chest wall displacement was measured using an ultrasonic detector. Nurses achieved successful ventilation in 74 (75%) of cases with the laryngeal mask airway and 76 (77%) with facemask and oropharyngeal airway (pu2003=u20030.89). Median (IQR [range]) time to first breath was longer for the laryngeal mask airway (48 (39–65 [8–149]))u2003s than the facemask/airway (35 (25–53 [14–120])u2003s; pu2003<u20030.0001). In 10 cases (10%) the lungs were ventilated using the laryngeal mask airway but not using the facemask/oropharyngeal airway. We conclude that ventilation is achieved rapidly using a facemask and oropharyngeal airway, and that the laryngeal mask airway may represent a useful second line option for first responders.

Study protocol: The Intensive Care Outcome Network ('ICON') study

BackgroundExtended follow-up of survivors of ICU treatment has shown many patients suffer long-term physical and psychological consequences that affect their health-related quality of life. The current lack of rigorous longitudinal studies means that the true prevalence of these physical and psychological problems remains undetermined.Methods/DesignThe ICON (Intensive Care Outcome Network) study is a multi-centre, longitudinal study of survivors of critical illness. Patients will be recruited prior to hospital discharge from 20–30 ICUs in the UK and will be assessed at 3, 6, and 12 months following ICU discharge for health-related quality of life as measured by the Short Form-36 (SF-36) and the EuroQoL (EQ-5D); anxiety and depression as measured by the Hospital Anxiety and Depression Scale (HADS); and post traumatic stress disorder (PTSD) symptoms as measured by the PTSD Civilian Checklist (PCL-C). Postal questionnaires will be used.DiscussionThe ICON study will create a valuable UK database detailing the prevalence of physical and psychological morbidity experienced by patients as they recover from critical illness. Knowledge of the prevalence of physical and psychological morbidity in ICU survivors is important because research to generate models of causality, prognosis and treatment effects is dependent on accurate determination of prevalence. The results will also inform economic modelling of the long-term burden of critical illness.Trial RegistrationISRCTN69112866