Jane Eddleston

Rehabilitation after critical illness: A randomized, controlled trial

ObjectiveTo evaluate the effectiveness of a rehabilitation program following critical illness to aid physical and psychological recovery. DesignRandomized controlled trial, blind at follow-up with final assessment at 6 months. SettingTwo district general hospitals and one teaching hospital. PatientsPatients were 126 consecutively admitted intensive care patients meeting the inclusion criteria. InterventionsControl patients received ward visits, three telephone calls at home, and clinic appointments at 8 wks and 6 months. Intervention patients received the same plus a 6-wk self-help rehabilitation manual. Measurements and Main ResultsWe measured levels of depression and anxiety (Hospital Anxiety and Depression Scale), phobic symptoms (Fear Index), posttraumatic stress disorder (PTSD)-related symptoms (Impact of Events Scale), and scores on the Short-Form Health Survey physical dimension 8 wks and 6 months after intensive care unit (ICU) treatment. Memory for ICU was assessed at 2 wks post-ICU discharge using the ICU Memory Tool.The intervention group improved, compared with the control patients, on the Short-Form Health Survey physical function scores at 8 wks and 6 months (p = .006), and there was a trend to a lower rate of depression at 8 wks (12% vs. 25%). However, there were no differences in levels of anxiety and PTSD-related symptoms between the groups. The presence of delusional memories was correlated significantly with both anxiety and Impact of Events Scale scores. ConclusionsA self-help rehabilitation manual is effective in aiding physical recovery and reducing depression. However, in those patients recalling delusional memories from the ICU, further psychological care may be needed to reduce the incidence of anxiety and PTSD-related symptoms.

Survival, morbidity, and quality of life after discharge from intensive care

Objective To assess survival, morbidity (physical and psychological), quality of life (QOL), and employment status of intensive care survivors up to 12 months after discharge from the intensive care unit (ICU). Design Prospective study. Setting University hospital adult ICU. Patients Between August 1, 1995, and July 31, 1996, 370 patients were admitted. Of these patients, 29% died in the ICU. Three months after discharge from the ICU, 227 patients were alive, and 143 agreed to participate. Cumulative mortality was calculated using the original complete cohort. Measurements and Main Results Demographic data, severity of acute illness (Acute Physiology and Chronic Health Evaluation [APACHE] II), admitting specialty, primary diagnosis, and length of stay were recorded. Physical and ICU-related psychological morbidity (Hospital Anxiety and Depression scale score) were recorded. Health-related QOL was assessed using the Short-Form 36. All the questionnaires were completed in the clinic at 3 months. Assessment of physical morbidity and employment status at 6 and 12 months were conducted by telephone. The cumulative mortality was 39% at 3 months, 41% at 6 months, and 43% at 12 months. Deaths after 3 months occurred in the group who refused follow-up. The median age for the follow-up group was 51 yrs; the gender split was 68 women and 75 men; the mean admission APACHE II score was 18.79 (sd 6.15); and the median length of ICU stay was 3.8 days. At 3 months, ∼80% of all patients interviewed were satisfied with their QOL. Older men (>65 yrs) and younger women (<65 yrs) demonstrated significantly better health with respect to some subdomains of the Short-Form 36 compared with their counterparts. The prevalence of psychological distress (Hospital Anxiety and Depression scale score, ≥8) was low: 11.9% had heightened anxiety, and 9.8% were depressed. There were high levels of fatigue, poor concentration, and sleep disturbance; the latter was more marked in women (p = .022). Improvement in all three symptoms occurred during the next 9 months. Significantly more women reported loss of hair (p < .0001). Men were slower to return to employment; 75% of women had returned by 6 months compared with only 65% of men at 1 yr. Conclusion Assessment of outcome after ICU stay must include QOL measurements. Three months after discharge, there is a low incidence of ICU-related psychological or psychiatric illness and the majority of patients are satisfied. Differences in the incidence and nature of morbidity exist between the genders.

The epidemiology of severe sepsis in England, Wales and Northern Ireland, 1996 to 2004: secondary analysis of a high quality clinical database, the ICNARC Case Mix Programme Database

IntroductionTo evaluate the impact of recent evidence-based treatments for severe sepsis in routine clinical care requires an understanding of the underlying epidemiology, particularly with regard to trends over time. We interrogated a high quality clinical database to examine trends in the incidence and mortality of severe sepsis over a nine-year period.MethodsAdmissions with severe sepsis occurring at any time within 24 hours of admission to critical care were identified to an established methodology using raw physiological data from the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme Database, containing data from 343,860 admissions to 172 adult, general critical care units in England, Wales and Northern Ireland between December 1995 and January 2005. Generalised linear models were used to assess changes in the incidence, case mix, outcomes and activity of these admissions.ResultsIn total, 92,672 admissions (27.0%) were identified as having severe sepsis in the first 24 hours following admission. The percentage of admissions with severe sepsis during the first 24 hours rose from 23.5% in 1996 to 28.7% in 2004. This represents an increase from an estimated 18,500 to 31,000 admissions to all 240 adult, general critical care units in England, Wales and Northern Ireland. Hospital mortality for admissions with severe sepsis decreased from 48.3% in 1996 to 44.7% in 2004, but the total number of deaths increased from an estimated 9,000 to 14,000. The treated incidence of severe sepsis per 100,000 population rose from 46 in 1996 to 66 in 2003, with the associated number of hospital deaths per 100,000 population rising from 23 to 30.ConclusionThe population incidence of critical care admission with severe sepsis during the first 24 hours and associated hospital deaths are increasing. These baseline data provide essential information to those wishing to evaluate the introduction of the Surviving Sepsis Campaign care bundles in UK hospitals.

A comparison of the frequency of stress ulceration and secondary pneumonia in sucralfate- or ranitidine-treated intensive care unit patients

ObjectiveTo compare the frequency of acute stress ulceration and secondary pneumonia caused by aerobic Gram-negative bacilli in ICU patients treated with either sucralfate or ranitidine. DesignProspective, randomized study. SettingICU, university hospital. PatientsSixty adult patients who were mechanically ventilated and at risk of developing stress ulceration. InterventionThe patients were randomized to receive either sucralfate (1 g every 6 hrs) via the nasogastric tube or iv ranitidine (50 mg every 6 hrs). If the gastric pH was <3.5 in the latter group, 30 mL of 0.3M sodium citrate was given via the nasogastric tube. Measurements and Main ResultsOn admission, the frequency rate of erosion/ulceration (assessed with the endoscope) was 13.5%. After 4 days, this rate had increased to 18% in sucralfate-treated patients and 36% in ranitidine-treated patients (NS). Mean gastric pH was more alkaline in the ranitidine-treated patients (5.50) compared with the sucralfate-treated patients (4.26) (p < .01). This pH permitted a higher occurrence rate of gastric colonization by aerobic Gram-negative bacilli in ranitidine-treated patients (64.3%) compared with sucralfate-treated patients (23.8%) (p < .01). Retrograde bacterial colonization from the stomach to oropharynx and trachea occurred more frequently in ranitidine-treated patients compared with sucralfate-treated patients. Ultimately, the occurrence rate of pneumonia was greater in the ranitidine-treated (35.7%) than in the sucralfate-treated patients (10.3%) (p < .05). ConclusionBased on our findings, we recommend the adoption of sucralfate for routine prophylaxis against stress ulceration. (Crit Care Med 1991; 19:1491)

Returning home after intensive care: A comparison of symptoms of anxiety and depression in ICU and elective cardiac surgery patients and their relatives

ObjectiveThis study gathered data on symptoms of anxiety and depression in patients and relatives after discharge from intensive care and examined whether the intensive care population differ from an elective cardiac surgery group with regards to their anxiety and depression symptom reporting.Design and settingA single measurement point matched group comparison study in an ICU follow-up programme.Patients and participantsTwenty ICU patients and their relatives and a matched comparison group of 15 elective cardiac surgery patients and their relatives.Measurements and resultsPatients and relatives completed the Hospital Anxiety and Depression Scale. Relatives answered an open question to explore the perceived impact of Intensive care/cardiac surgery on their lives. ICU patients’ relatives reported significantly higher number of symptoms of anxiety than did ICU patients, higher number of symptoms of depression than cardiac surgery patients’ relatives, and more troubling and life-altering experiences than the relatives of cardiac surgery patients.ConclusionsRelatives of ICU patients also suffer anxiety and depression, and services should address this need. Group differences suggest that ICU patients’ relatives have ‘unique’ characteristics of depression symptom reporting.

Prospective endoscopic study of stress erosions and ulcers in critically ill adult patients treated with either sucralfate or placebo

Objective: To compare the frequency of stress erosions and ulcers in critically ill adult patients treated with either sucralfate or placebo. Design: Prospective, randomized study. Setting: Intensive care unit in a university hospital. Patients: Twenty‐six adult patients. All patients were mechanically ventilated and were at risk of developing stress ulceration. Interventions: Patients were randomized to receive either sucralfate (2 g every 8 hrs) (group 1) via the nasogastric tube (flushed with 10 mL of sterile water) or 20 mL of sterile water every 8 hrs (group 2) via the nasogastric tube. Measurements and Main Results: At the time of intensive care unit admission, the frequency of stress (acute) erosions (as assessed with the endoscope) was 21.7%. No ulcers were detected. By day 3, the frequency had increased to 37.5% in group 1 and 88.9% in group 2. Mucosal deterioration was more likely in the patients treated with placebo (water) ( p < .05). In total, seven patients developed acute ulceration in group 2 compared with only one patient in group 1 ( p < .05). The frequency of gastric colonization with aerobic Gram‐negative bacilli was 25.6% in group 1 and 28.6% in group 2. Only one retrograde nosocomial pneumonia developed (group 1). Conclusion: Based on our findings, we strongly recommend the adoption of sucralfate as opposed to no prophylaxis in the prevention of acute upper gastrointestinal ulceration. (Crit Care Med 1994; 22:1949–1954)

Open pancreatic necrosectomy in the multidisciplinary management of postinflammatory necrosis.

Objective:To examine clinical outcome in a consecutive cohort of patients undergoing open necrosectomy for postinflammatory necrosis. Background Information:The last decade has witnessed major developments in the surgical management of pancreatic necrosis. Minimally invasive approaches have become established. However, there are limited data from contemporary open necrosectomy, in particular where multidisciplinary care and aggressive interventional radiology are used. This report provides data on outcome from open necrosectomy in a tertiary referral Hepatobiliary unit over the last decade. Methods:During the period January 1, 2000 to July 31, 2008, 1535 patients were admitted with a final discharge code of acute pancreatitis. Twenty-eight (1.8%) of all admissions underwent open surgical necrosectomy. Twenty-four (86%) were tertiary referral patients. Results:The median APACHE II score on admission was 10.5 (5–26). Median logistic organ dysfunction score on admission was 3 (0–10). Median LODS score after surgery was 2 (0–8). Twenty patients (71%) underwent radiologically guided drainage of collections before surgery. Thirty-day mortality occurred in 2 (7%), 4 further deaths occurred in patients after discharge from intensive care resulting in a total of 6 (22%) episode-related deaths. Conclusions:Modern open necrosectomy can be performed without the procedure-related deterioration in organ dysfunction associated with major debridement. Multidisciplinary care with an emphasis on aggressive radiologic intervention before and after surgery results in acceptable outcomes in this cohort of critically ill patients. Newer laparoscopic techniques must demonstrate similar outcomes in the setting of stage-matched severity before wider acceptance.

Dopexamine reduces the incidence of acute inflammation in the gut mucosa after abdominal surgery in high-risk patients.

OBJECTIVE To evaluate the effect of dopexamine on the incidence of acute inflammation in the stomach/duodenum in patients undergoing abdominal surgery > or =1.5 hrs with a minimum of one high-risk criterion. DESIGN Prospective, randomized, double-blind, placebo-controlled study. This study was conducted as a side arm to a multicenter, multinational study. SETTING University hospital in an adult intensive care unit. PATIENTS Thirty-eight patients. INTERVENTIONS Patients were stabilized with fluid, blood products, and supplementary oxygen to achieve predetermined goals: cardiac index > 2.5 L/min/m2, mean arterial blood pressure of 70 mm Hg, pulmonary arterial occlusion pressure of 10 mm Hg, hemoglobin of 100 g/L, and arterial saturation of 94%. After stabilization, the study drug (either placebo [group A], dopexamine 0.5 microg/kg/min [group B], or dopexamine 2.0 microg/kg/min [group C]) was commenced. The study drug infusion was started 2 to 12 hrs before surgery and infused for 24 hrs after surgery. Estimation of upper gut blood flow was assessed using a gastric tonometer, and gastroscopy with biopsy was performed before surgery (after induction of anesthesia) and 72 hrs after surgery. Comparisons were made between endoscopic findings and histologic proof of acute inflammatory changes. In addition, biopsies were assessed for the presence in the mucosa of mast cells, myeloperoxidase activity, and inducible nitric oxide synthase. MEASUREMENTS AND MAIN RESULTS Intramucosal pH decreased significantly with time in all three groups (p < .001), reaching the lowest point at the end of surgery. There was no difference among the groups. Endoscopy visualized acute inflammatory changes in 58.3% of group A patients, 46.2% of group B patients, and 53.90% of group C patients after hemodynamic optimization. At 72 hrs, dopexamine-treated patients compared with placebo-treated patients had a significantly lower incidence of gastric and duodenal acute inflammatory changes, as defined by myeloperoxidase activity (37.5% in groups B and C vs. 86% in group A; p < .05). CONCLUSION Dopexamine in doses of 0.5 and 2.0 microg/kg/min affords significant histologic protection to the upper gastrointestinal tract mucosa 72 hrs after operation in high-risk surgical patients undergoing abdominal surgery.

The use of propofol for sedation of critically ill patients undergoing haemodiafiltration

ObjectiveTo assess the requirement for propofol to provide sedation in critically ill patients in established renal failure during the commencement of haemodiafiltration.DesignProspective clinical study.SettingICU, University Hospital.Patients10 adult patients. All were mechanically ventilated, had acute oliguric renal failure which necessitated continuous veno-venous haemodiafiltration and were receiving a continuous intravenous infusion of propofol for sedation. Sedation was assessed using a scoring system.InterventionVeno-venous haemodiafiltration.Measurements and resultsConnection of the extracorporeal circuit produced a reduction in plasma propofol concentration in 7 out of 9 patients (one sample misplaced) with subsequent awakening in 3 of these 7 patients. The commencement of haemodiafiltration itself did not significantly influence the requirement for propofol (8 out of 10 patients).ConclusionHaemodiafiltration does not substantially influence the requirement for propofol but the initial introduction of the extracorporeal circuit will reduce plasma concentrations in the majority of patients. This may be due to haemodilution alone or absorption of plasma albumin (with propofol) onto the membrane.

Improving rehabilitation after critical illness through outpatient physiotherapy classes and essential amino acid supplement: A randomized controlled trial.

PURPOSE Patients recovering from critical illness may be left with significant muscle mass loss. This study aimed to evaluate whether a 6-week program of enhanced physiotherapy and structured exercise (PEPSE) and an essential amino acid supplement drink (glutamine and essential amino acid mixture [GEAA]) improves physical and psychological recovery. MATERIALS AND METHODS Intensive care patients aged 45 years or older, with a combined intensive care unit stay/pre-intensive care unit stay of 5 days or more were recruited to a randomized controlled trial examining the effect of PEPSE and GEAA on recovery. The 2 factors were tested in a 2 × 2 factorial design: (1) GEAA drink twice daily for 3 months and (2) 6-week PEPSE in first 3 months. Primary efficacy outcome was an improvement in the 6-minute walking test at 3 months. RESULTS A total of 93 patients were randomized to the study. Patients receiving the PEPSE and GEA had the biggest gains in distance walked in 6-minute walking test (P < .0001). There were also significant reductions in rates of anxiety in study groups control supplement/PEPSE (P = .047) and GEAA supplement/PEPSE (P = .036) and for GEAA supplement/PEPSE in depression (P = .0009). CONCLUSION Enhanced rehabilitation combined with GEAA supplement may enhance physical recovery and reduce anxiety and depression.