Marike van der Schaaf

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.

Functional outcome in patients with critical illness polyneuropathy

Purpose: To evaluate the functional outcome of intensive care patients with critical illness polyneuropathy (CIP), 6 and 12 months after the onset. Methods: Design: A prospective observational cohort study and a cross-sectional study. Setting: University hospital in the Netherlands. Patients: Eight consecutive intensive care patients with CIP for the prospective study and eight patients diagnosed with CIP in the past 6 months for the cross-sectional study. Main outcome measures: Functional outcome regarding body functions and structure, activities, participation and perceived quality of life. Results: Nine patients (56%) died within one year. Functional outcome, participation and subjective health status in survivors varied widely at 6 and 12 months. After 12 months, physical functioning was improved in all patients. However activities related to mobility outdoors, autonomy, participation and quality of life were restricted in most patients. Conclusions: The majority of survivors have persistent functional disabilities in activities, reduced quality of life and restrictions in autonomy and participation one year after the onset of CIP. Prolonged rehabilitation treatment is necessary for an increasing number of intensive care patients who develop CIP, in order to reduce handicaps and achieve optimal autonomy and social participation.

Feasibility and effectiveness of pre-operative inspiratory muscle training in patients undergoing oesophagectomy: a pilot study

BACKGROUND Patients undergoing oesophageal surgery have a high risk for post-operative complications including pulmonary infections. Recently, physical therapy has shifted from the post-operative to the pre-operative phase to diminish post-operative complications and to shorten hospital stay. The purpose of this pilot study was to investigate the feasibility and initial effectiveness of pre-operative inspiratory muscle training (IMT) on the incidence of pneumonia in patients undergoing oesophagectomy. METHODS A pragmatic non-randomized controlled trial was conducted among all patients who underwent an oesophagectomy between January 2009 and February 2010. Patients in the intervention group received IMT prior to surgery. Feasibility was assessed on the basis of the occurrence of adverse effects during testing or training and patient satisfaction. Initial effectiveness on respiratory function was evaluated by maximal inspiratory pressure (MIP) and endurance, the incidence of post-operative pneumonia and length of hospital stay. RESULTS Eighty-three patients were included, of which 44 received pre-operative IMT. No adverse effects were observed. IMT was well tolerated and appreciated. In the intervention group, the median MIP and endurance improved significantly after IMT by 32% and 41%, respectively (p < 0.001). The incidence of post-operative pneumonia and the length of hospital stay were comparable for the intervention and the conventional care groups (pneumonia, 25% vs. 23% [p = 0.84]; hospitalization, 13.5 vs. 12 days [p = 0.08]). CONCLUSIONS Pre-operative IMT is feasible in patients with oesophageal carcinoma and significantly improves respiratory muscle function. This, however, did not result in a reduction of post-operative pneumonia in patients undergoing oesophagectomy.

Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations

Objective: To develop evidence-based recommendations for effective and safe diagnostic assessment and intervention strategies for the physiotherapy treatment of patients in intensive care units. Methods: We used the EBRO method, as recommended by the ‘Dutch Evidence Based Guideline Development Platform’ to develop an ‘evidence statement for physiotherapy in the intensive care unit’. This method consists of the identification of clinically relevant questions, followed by a systematic literature search, and summary of the evidence with final recommendations being moderated by feedback from experts. Results: Three relevant clinical domains were identified by experts: criteria to initiate treatment; measures to assess patients; evidence for effectiveness of treatments. In a systematic literature search, 129 relevant studies were identified and assessed for methodological quality and classified according to the level of evidence. The final evidence statement consisted of recommendations on eight absolute and four relative contra-indications to mobilization; a core set of nine specific instruments to assess impairments and activity restrictions; and six passive and four active effective interventions, with advice on (a) physiological measures to observe during treatment (with stopping criteria) and (b) what to record after the treatment. Conclusions: These recommendations form a protocol for treating people in an intensive care unit, based on best available evidence in mid-2014.

Impact of ICU-acquired weakness on post-ICU physical functioning: a follow-up study

IntroductionICU-acquired weakness is thought to mediate physical impairments in survivors of critical illness, but few studies have investigated this thoroughly. The purpose was to investigate differences in post-ICU mortality and physical functioning between patients with and without ICU-acquired weakness at 6 months after ICU discharge.MethodICU patients, mechanically ventilated ≥2 days, were included in a single-center prospective observational cohort study. ICU-acquired weakness was diagnosed when the average Medical Research Council score was <4 in awake and attentive patients. Post-ICU mortality was recorded until 6 months after ICU discharge; in surviving patients, physical functioning was assessed using the Short-Form Health Survey physical functioning domain. The independent effect of ICU-acquired weakness on post-ICU mortality was analyzed using a multivariable Cox proportional hazards model. The independent effect of ICU-acquired weakness on the physical functioning domain score was analyzed using a multivariable linear regression model.ResultsOf the 156 patients included, 80 had ICU-acquired weakness. Twenty-three patients died in the ICU (20 with ICU-acquired weakness); during 6 months follow-up after ICU discharge another 25 patients died (17 with ICU-acquired weakness). Physical functioning domain scores were available for 96 survivors (39 patients with ICU-acquired weakness). ICU-acquired weakness was independently associated with an increase in post-ICU mortality (hazard ratio 3.6, 95% confidence interval, 1.3 to 9.8; P = 0.01) and with a decrease in physical functioning (β: -16.7 points; 95% confidence interval, -30.2 to -3.1; P = 0.02).ConclusionICU-acquired weakness is independently associated with higher post-ICU mortality and with clinically relevant lower physical functioning in survivors at 6 months after ICU discharge.

No evidence for the effectiveness of bracing in patients with thoracolumbar fractures: A systematic review

Background and purpose The use of braces is widespread in patients with thoracolumbar fractures. The effectiveness of bracing, however, is controversial. We sought evidence for the effect of bracing in patients with traumatic thoracolumbar fractures based on outcome and length of hospital stay (LOS). Furthermore, we evaluated the incidence of complications of bracing. Methods An electronic search strategy with extensive MeSH headings was used in various databases to identify studies that compared bracing and non-bracing therapies. Two reviewers independently selected systematic reviews, randomized controlled trials (RCTs), controlled clinical trials, and observational studies, and both assessed the methodological quality and extracted the data. Results No systematic reviews or RCTs were found. 7 retrospective studies were included. None of these studies showed an effect of bracing. Because of poor methodological quality, no best-evidence synthesis could be performed. One observational study was selected in which a complication of bracing was reported. Interpretation In the present literature, there is no evidence for the effectiveness of bracing in patients with traumatic thoracolumbar fractures. The lack of high-quality studies prevents relevant conclusions from being drawn.

Caregiver strain and posttraumatic stress symptoms of informal caregivers of intensive care unit survivors

BACKGROUND Many intensive care unit survivors (ICU) are confronted with undesirable and long-lasting impairments in physical, cognitive, and mental health, but not only patients are at risk of developing this post-intensive care syndrome (PICS). Family members can experience symptoms of depression, anxiety, and posttraumatic stress disorder (PTSD). This cluster of complications is called PICS-family. OBJECTIVE To describe the level of caregiver strain and posttraumatic stress-related symptoms in relatives of ICU survivors. METHODS We conducted a cohort study in a general hospital between July 2010 and May 2014. Relatives of ICU survivors, mechanically ventilated for > 48 h in the ICU, were asked to complete a questionnaire 3 months after discharge from critical care. Symptoms of PTSD and caregiving concerns were assessed using the Trauma Screening Questionnaire and the Caregiver Strain Index (CSI). RESULTS A total of 94 relatives visiting our post-ICU clinic completed the questionnaires. Twenty-one percent of the caregivers had a CSI score of 7 or more, indicating high levels of strain. Six percent had CSI scores indicating severe strain (CSI > 10). PTSD-related symptoms were seen in 21% of the caregivers. The mean time spent on caregiving was 10 h (interquartile range 6-17 h) per week. CONCLUSION This study shows that relatives of ICU survivors could experience strain 3 months after hospital discharge and are at risk of developing PTSD-related symptoms. This complements existing data that relatives are at risk of psychological symptoms. Knowledge can lead to improvements and means to prevent these symptoms. (PsycINFO Database Record

Early prediction of intensive care unit-acquired weakness using easily available parameters: a prospective observational study.

Introduction An early diagnosis of Intensive Care Unit–acquired weakness (ICU–AW) using muscle strength assessment is not possible in most critically ill patients. We hypothesized that development of ICU–AW can be predicted reliably two days after ICU admission, using patient characteristics, early available clinical parameters, laboratory results and use of medication as parameters. Methods Newly admitted ICU patients mechanically ventilated ≥2 days were included in this prospective observational cohort study. Manual muscle strength was measured according to the Medical Research Council (MRC) scale, when patients were awake and attentive. ICU–AW was defined as an average MRC score <4. A prediction model was developed by selecting predictors from an a–priori defined set of candidate predictors, based on known risk factors. Discriminative performance of the prediction model was evaluated, validated internally and compared to the APACHE IV and SOFA score. Results Of 212 included patients, 103 developed ICU–AW. Highest lactate levels, treatment with any aminoglycoside in the first two days after admission and age were selected as predictors. The area under the receiver operating characteristic curve of the prediction model was 0.71 after internal validation. The new prediction model improved discrimination compared to the APACHE IV and the SOFA score. Conclusion The new early prediction model for ICU–AW using a set of 3 easily available parameters has fair discriminative performance. This model needs external validation.