Brief description of media:

In this multicenter cohort study, one or more PICS problems were present in the majority of survivors, but co-occurring problems were present in only 1 out of 4. Education was protective from PICS and frailty predictive of the development of PICS. Future studies are needed to understand better the heterogeneous subtypes of PICS and to identify modifiable risk factors.

Brief description of media:

Background
Illnesses that necessitate intensive care can impair cognitive function severely over the long term, leaving patients less able to cope with the demands of everyday living and markedly lowering their quality of life. There has not yet been any comprehensive study of the cognitive sequelae of critical illness among non-surgical patients treated in intensive care. The purpose of this review is to present the available study findings on cognitive deficits in such patients, with particular attention to prevalence, types of deficit, clinical course, risk factors, prevention, and treatment.
Methods
This review is based on pertinent publications retrieved by a selective search in MEDLINE.
Results
The literature search yielded 3360 hits, among which there were 14 studies that met our inclusion criteria. 17–78% of patients had cognitive deficits after discharge from the intensive care unit; most had never had a cognitive deficit before. Cognitive impairment often persisted for up to several years after discharge (0.5 to 9 years) and tended to improve over time. The only definite risk factor is delirium.
Conclusion
Cognitive dysfunction is a common sequela of the treatment of non-surgical patients in intensive care units. It is a serious problem for the affected persons and an increasingly important socio-economic problem as well. The effective management of delirium is very important. General conclusions are hard to draw from the available data because of heterogeneous study designs, varying methods of measurement, and differences among patient cohorts. Further studies are needed so that study designs and clinical testing procedures can be standardized and effective measures for prevention and treatment can be identified.

Brief description of media:

Around a quarter of patients treated in intensive care units (ICUs) will develop symptoms of post-traumatic stress disorder (PTSD). Given the dramatic increase in ICU admissions during the COVID-19 pandemic, clinicians are likely to see a rise in post-ICU PTSD cases in the coming months. Post-ICU PTSD can present various challenges to clinicians, and no clinical guidelines have been published for delivering trauma-focused cognitive behavioral therapy with this population. In this article, we describe how to use cognitive therapy for PTSD (CT-PTSD), a first line treatment for PTSD recommended by the National Institute for Health and Care Excellence. Using clinical case examples, we outline the key techniques involved in CT-PTSD and describe their application to treating patients with PTSD following ICU.

Brief description of media:

Around a quarter of patients treated in intensive care units (ICUs) will develop symptoms of post-traumatic stress disorder (PTSD). Given the dramatic increase in ICU admissions during theCOVID-19 pandemic, clinicians are likely to see a rise in post-ICU PTSD cases in the coming months. Post-ICU PTSD can present various challenges to clinicians, and no clinical guidelines have been published for delivering trauma-focused cognitive behavioral therapy with this population. In this article, we describe how to use cognitive therapy for PTSD (CT-PTSD), a first line treatment for PTSD recommended by the National Institute for Health and Care Excellence. Using clinical case examples, we outline the key techniques involved in CT-PTSD and describe their application to treating patients with PTSD following ICU.

Brief description of media:

Around a quarter of patients treated in intensive care units (ICUs) will develop symptoms of post-traumatic stress disorder (PTSD). Given the dramatic increase in ICU admissions during the COVID-19 pandemic, clinicians are likely to see a rise in post-ICU PTSD cases in the coming months. Post-ICU PTSD can present various challenges to clinicians, and no clinical guidelines have been published for delivering trauma-focused cognitive behavioral therapy with this population. In this article, we describe how to use cognitive therapy for PTSD (CT-PTSD), a first line treatment for PTSD recommended by the National Institute for Health and Care Excellence. Using clinical case examples, we outline the key techniques involved in CT-PTSD and describe their application to treating patients with PTSD following ICU.

Brief description of media:

Rationale: The US has seven times as many intensive care unit (ICU) beds per capita as the UK; the effect on care of critically ill patients is unknown.

Objective: Compare medical ICU admission in the US and UK.

Methods: Retrospective (2002-2004) cohort study of 172,785 admissions (137 US ICUs, Project IMPACT database; 160 UK ICUs, UK Case Mix Program), with patients followed until initial hospital discharge.

Results: UK (vs US) admissions were less likely to be admitted directly from the emergency room (ER), (33.4 vs 58.0%), had longer hospital stays before ICU admission (mean days 2.6±8.2 vs 1.0±3.6), and fewer were ≥85 years (3.2% vs 7.8%). UK patients were more frequently mechanically ventilated within 24h after ICU admission (68.0% vs 27.4%), were sicker (mean Acute Physiology Score 16.7±7.6 vs 10.6±6.8) and had higher primary hospital mortality (38.0% vs 15.9%; adjusted Odds Ratio (OR) 1.73, 95%CI 1.50-1.99). There was no mortality difference for mechanically ventilated patients admitted from the ER (adjusted OR 1.09, 0.89-1.33). Comparisons of hospital mortality were confounded by differences in case mix, hospital length of stay (UK median 10 days (IQR 3-24) vs US 6 (3-11)), and discharge practices: more US patients were discharged to skilled care facilities (29.0% of survivors vs 6.0% in the UK).

Conclusions: Lower UK ICU bed availability is associated with fewer direct admissions from the ER, longer hospital stays before ICU admission, and higher severity of illness. Interpretation of between-country hospital outcomes is confounded by differences in case mix, processes of care and discharge practices.

Brief description of media:

The service deals with the management of children with serious tracheal disease in childhood. It is primarily concerned with the treatment of long segment congenital tracheal stenosis (and its associated [60%] lesions), severe trachea bronchomalacia and a variety of other, rarer pathologies. Management involves assessment of airway disease by bronchoscopy, bronchography, optical coherence tomography, echocardiography, 3-D imaging by computed tomography (CT) and magnetic resonance imaging (MRI). Treatment may involve surgery, for example slide tracheoplasty for tracheal stenosis, or stenting for malacia. Follow up is both by shared care with referring institutions but by annual review at Great Ormond Street Hospital for Children NHS Foundation Trust (GOSH) with anatomic, physiologic, and quality of life assessment.

Brief description of media:

An increased proportion of deaths occur in the intensive care unit (ICU). We performed this prospective study in 41 ICUs to determine the prevalence and determinants of complicated grief after death of a loved one in the ICU. Relatives of 475 adult patients were followed up. Complicated grief was assessed at 6 and 12 months using the Inventory of Complicated Grief (cut-off score>25). Relatives also completed the Hospital Anxiety and Depression Scale at 3 months, and the Revised Impact of Event Scale for post-traumatic stress disorder symptoms at 3, 6 and 12 months. We used a mixed multivariate logistic regression model to identify determinants of complicated grief after 6 months. Among the 475 patients, 282 (59.4%) had a relative evaluated at 6 months. Complicated grief symptoms were identified in 147 (52%) relatives.

Independent determinants of complicated grief symptoms were either not amenable to changes (relative of female sex, relative living alone and intensivist board certification before 2009) or potential targets for improvements (refusal of treatment by the patient, patient died while intubated, relatives present at the time of death, relatives did not say goodbye to the patient, and poor communication between physicians and relatives). End-of-life practices, communication and loneliness in bereaved relatives may be amenable to improvements.

Brief description of media:

Purpose—To describe the design and initial implementation of an Intensive Care Unit Recovery Center (ICU-RC) in the United States.

Materials and Methods—A prospective, observational feasibility study was undertaken at an academic hospital between July 2012 and December 2015. Clinical criteria were used to develop the ICU-RC, identify patients at high risk for post intensive care syndrome (PICS), and offer them post-ICU care.

Results—218/307 referred patients (71%) survived to hospital discharge; 62 (28% of survivors) were seen in clinic. Median time from discharge to ICU-RC visit was 29 days. At initial evaluation, 64% of patients had clinically meaningful cognitive impairment. Anxiety and depression were present in 37% and 27% of patients, respectively. One in three patients was unable to ambulate independently; median 6-minute walk distance was 56% predicted. Of 47 previously working patients, 7 (15%) had returned to work. Case management and referral services were provided 142 times. The median number of interventions per patient was 4.

Conclusions—An ICU-RC identified a high prevalence of cognitive impairment, anxiety, depression, physical debility, lifestyle changes, and medication-related problems warranting intervention. Whether an ICU-RC can improve ICU recovery in the US should be investigated in a systematic way.

Brief description of media:

To describe the design and initial implementation of an Intensive Care Unit Recovery Center (ICU-RC) in the United States. A prospective, observational feasibility study was undertaken at an academic hospital between July 2012 and December 2015. Clinical criteria were used to develop the ICU-RC, identify patients at high risk for post intensive care syndrome (PICS), and offer them post-ICU care.

218/307 referred patients (71%) survived to hospital discharge; 62 (28% of survivors) were seen in clinic. Median time from discharge to ICU-RC visit was 29days. At initial evaluation, 64% of patients had clinically meaningful cognitive impairment. Anxiety and depression were present in 37% and 27% of patients, respectively. One in three patients was unable to ambulate independently; median 6min walk distance was 56% predicted. Of 47 previously working patients, 7 (15%) had returned to work. Case management and referral services were provided 142 times. The median number of interventions per patient was 4.

An ICU-RC identified a high prevalence of cognitive impairment, anxiety, depression, physical debility, lifestyle changes, and medication-related problems warranting intervention. Whether an ICU-RC can improve ICU recovery in the US should be investigated in a systematic way.

Brief description of media:

Over 6 million patients become critically ill each year. Of these, an increasing number will survive due to advances in critical care. However, this survival is not without cost. As the long-term effects of critical illness become known, the need to design and implement effective interventions to rescue critical illness survivors from incomplete recovery has become a pressing priority for many clinicians. However, evidence-based guidelines for intensive care unit (ICU) follow up and recovery remain elusive. In 2012, we started seeing patients in an outpatient team clinic designed to screen for and treat Post Intensive Care Syndrome (PICS), with the goal of promoting recovery for the sickest patients who survive the ICU. This effort was inspired by a patient in the Vanderbilt Medical ICU and was undertaken as a pragmatic clinical intervention in an attempt to address the multifaceted yet ICU-specific problems emerging in the literature and in practice.

Brief description of media:

The family is one of the basic units of society and has a great influence on its members. When a family member becomes ill, the illness affects the well-being of other family members, causing changes in the life of the whole family. Critical illness often occurs without warning and there is little time for patients and their families to prepare. If family members’ immediate needs can be met, desirable consequences for both family members and patients can be achieved. In order to meet family member’s needs, critical care units’ nurses must be able to identify their needs accurately [1, 2]. Every year in the United States, approximately 20% of all deaths occur in an intensive care unit (ICU), and family members suffer from being withdrawn or withheld. Many of patients are unable to communicate because of sedation, mechanical ventilation, confusion, and comatose. This results in much of the burden of decision-making and treatment choices on the patients’ family members. This may affect family members by increasing their stress levels and increasing their risk for psychological and physical symptoms [3].