Lakshmipathi Chelluri

Patients' recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit*

Objective To describe stressful experiences of adult patients who received mechanical ventilation for ≥48 hrs in an intensive care unit. Design Prospective cohort study. Setting Four intensive care units within an East Coast tertiary-care university medical center. Patients Patients were 150 adult intensive care unit patients receiving mechanical ventilation for ≥48 hrs. Intervention None. Measurements and Main Results As part of a study of the long-term outcomes of adult patients requiring prolonged mechanical ventilation, we used a 32-item questionnaire to collect data on patients’ stressful experiences, both psychological (e.g., fearfulness, anxiety) and physical (e.g., pain, difficulty breathing), associated with the mechanical ventilation endotracheal tube and with being in an intensive care unit.Of 554 patients who met study criteria and survived prolonged mechanical ventilation, 150 consented and were oriented to person, place, and situation. Two thirds of these patients remembered the endotracheal tube and/or being in an intensive care unit. The median numbers of endotracheal tube and intensive care unit experiences remembered were 3 (of 7) and 9 (of 22), respectively. If a patient remembered an experience in the questionnaire, it was likely to be moderately to extremely bothersome.Some of the items that many patients found to be moderately to extremely bothersome were pain, fear, anxiety, lack of sleep, feeling tense, inability to speak/communicate, lack of control, nightmares, and loneliness. Stressful experiences associated with the endotracheal tube were strongly associated with subjects’ experiencing spells of terror, feeling nervous when left alone, and poor sleeping patterns. Conclusions Subjects were more likely to remember experiences that were moderately to extremely bothersome. This might be because the more bothersome experiences were easier to recall or because most of these experiences are common and significant stressors to many of these patients. In either case, these data indicate that these patients are subject to numerous stressful experiences, which many find quite bothersome. This suggests the potential for improved symptom management, which could contribute to a less stressful intensive care unit stay and improved patient outcomes.

Long-term mortality and quality of life after prolonged mechanical ventilation*

ObjectiveTo describe and identify factors associated with mortality rate and quality of life 1 yr after prolonged mechanical ventilation. DesignProspective, observational cohort study with patient recruitment over 26 months and follow-up for 1 yr. SettingIntensive care units at a tertiary care university hospital. PatientsAdult patients receiving prolonged mechanical ventilation. InterventionsNone. Measurements and Main ResultsWe measured mortality rate and functional status, defined as the inability to perform instrumental activities of daily living (IADLs) 1 yr following prolonged mechanical ventilation. The study enrolled 817 patients. Their median age was 65 yrs, 46% were women, and 44% were alive at 1 yr. Median ages at baseline of 1-yr survivors and nonsurvivors were 53 and 71 yrs, respectively. At the time of admission to the hospital, survivors had fewer comorbidities, lower severity of illness score, and less dependence compared with nonsurvivors. Severity of illness on admission to the intensive care unit and prehospitalization functional status had a significant association with short-term mortality rate, whereas age and comorbidities were related to long-term mortality. Fifty-seven percent of the surviving patients needed caregiver assistance at 1 yr of follow-up. The odds of having IADL dependence at 1-yr among survivors was greater in older patients (odds ratio 1.04 for 1-yr increase in age) and those with IADL dependence before hospitalization (odds ratio 2.27). ConclusionsMortality rate after prolonged mechanical ventilation is high. Long-term mortality rate is associated with older age and poor prehospitalization functional status. Many survivors needed assistance after discharge from the hospital, and more than half still required caregiver assistance at 1 yr. Interventions providing support for caregivers and patients may improve the functional status and quality of life of both groups and thus need to be evaluated.

Outcome of intensive care of the "oldest-old" critically ill patients.

Objective:To determine the short-term and long-term outcome of critically ill “oldest-old” (≥85 yrs) patients. Design:Retrospective chart review and follow-up telephone interview. Setting:ICUs at a tertiary care hospital. Methods:The medical records of all patients ≥85 yrs of age admitted to the ICUs during 1988 were reviewed. Demographic information, severity of illness, major interventions, mortality rate, and hospital charges were examined. A follow-up telephone interview was conducted to determine the quality of life and mortality rate after discharge. Results:Of 34 patients ≥85 yrs of age admitted to the ICU, 21 (62%) survived to discharge from the hospital, and 13 (62%) of these 21 patients were discharged to home. Mean ± so hospital charges were

Differences in one-year health outcomes and resource utilization by definition of prolonged mechanical ventilation: a prospective cohort study

34,738 ± 34,366. Seventeen of the 21 patients were contacted for long-term follow-up, and ten of these patients were alive at a mean follow-up time of 18 ± 10 months (range 1 to 32). Eight of the ten patients described their quality of life as fair or good. Conclusion:These findings suggest that age alone may be an inappropriate criterion for allocation of ICU resources.

An economic evaluation of prolonged mechanical ventilation.

IntroductionThe outcomes of patients ventilated for longer than average are unclear, in part because of the lack of an accepted definition of prolonged mechanical ventilation (PMV). To better understand the implications of PMV provision, we compared one-year health outcomes between two common definitions of PMV as well as between PMV patients and those ventilated for shorter periods of time.MethodsWe conducted a secondary analysis of prospectively collected data from medical and surgical intensive care units at an academic tertiary care medical center. The study included 817 critically ill patients ventilated for ≥ 48 hours, 267 (33%) of whom received PMV based on receipt of a tracheostomy and ventilation for ≥ 96 hours. A total of 114 (14%) patients met the alternate definition of PMV by being ventilated for ≥ 21 days. Survival, functional status, and costs were measured at baseline and at 2, 6, and 12 months after discharge. Of one-year survivors, 71 (17%) were lost to follow up.ResultsPMV patients ventilated for ≥ 21 days had greater costs (

Outcomes Associated With Delirium in Older Patients in Surgical ICUs

140,409 versus

Hospital costs in patients receiving prolonged mechanical ventilation: Does age have an impact?

143,389) and higher one-year mortality (58% versus 48%) than did PMV patients with tracheostomies who were ventilated for ≥ 96 hours. The majority of PMV deaths (58%) occurred after hospital discharge whereas 67% of PMV patients aged 65 years or older had died by one year. At one year PMV patients on average had limitations in two basic and five instrumental elements of functional status that exceeded both their pre-admission status and the one-year disability of those ventilated for < 96 hours. Costs per one-year survivor were

Quality of life and dialysis decisions in critically ill patients with acute renal failure

423,596,

How patients feel about prolonged mechanical ventilation 1 yr later

266,105, and

Pharmacokinetics of amikacin during continuous veno-venous hemofiltration.

165,075 for patients ventilated ≥ 21 days, ≥ 96 hours with a tracheostomy, and < 96 hours, respectively.ConclusionContrasting definitions of PMV capture significantly different patient populations, with ≥ 21 days of ventilation specifying the most resource-intensive recipients of critical care. PMV patients, particularly the elderly, suffer from a significant burden of costly, chronic critical illness and are at high risk for death throughout the first year after intensive care.