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This manuscript provides support for physical therapists to focus on the long-term, as well as the short-term, consequences of acute respiratory distress syndrome (ARDS) associated with COVID-19. Since late November 2019, COVID-19 has become a global health pandemic and threat. Although most people have no or mild symptoms, COVID-19 spreads aggressively and can lead to ARDS rapidly
in a proportion of individuals. The evidence supports that gas exchange and countering the negative effects of bed rest and immobility are priorities in severely affected patients admitted to the intensive care unit (ICU). However, in recent years, research has focused on poor long-term functional outcomes
in patients with ARDS, often associated with ICU-acquired weakness, deconditioning, and myopathies and neuropathies. In addition to physical therapists providing respiratory support in the ICU, the literature unequivocally supports the view that early intervention for ICU management of patients with ARDS secondary to COVID-19 needs to focus on reducing contributors to impaired long-term function, with direct attention paid to preventing or managing ICU-acquired weakness, decondition-ing, and myopathies and neuropathies, in conjunction with respiratory care.

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Post-hospital medical resource use among ICU
survivors is substantial, although similar to that after non-ICU
hospitalization. Although the fraction of survivors unable to
live independently was small, a larger fraction required home
care services. Identifying post-hospital supports needed by ICU
survivors can be useful for policy makers and others responsible
for healthcare planning.

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As awareness has grown of the great distress intensive care patients may suffer, units have begun recruiting psychologists to their teams. Intensive care unit psychologists aim to assess and reduce distress for patients, families and staff, to improve outcomes. This paper summarises research on the psychological impact of critical illness, highlights the growth of critical care health psychology as a speciality, and discusses potential roles of psychologists and the evidence base for psychological interventions in critical care departments.

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Post Intensive Care Syndrome (PICS) describes a set of disorders that are common in patients with severe illness and / or intensive care. Since the majority of the literature in intensive care medicine focuses on short-term outcomes (for example, survival), understanding of the patient's long-term development is relatively limited, since the latter is then considered to be healed.

Cognitive impairment includes deficits in memory, attention, speed of mental processing and problem solving. These impairments affect up to 80% of people who have experienced a serious illness. Most patients' symptoms improve or even disappear completely within the first year after treatment in the intensive care unit.

The underlying pathophysiology of cognitive impairment in critical care survivors is not well understood, but prolonged inflammation can play an important role

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Introduction
Relatives of patients with severe sepsis have high risk of adverse psychological outcomes. Better knowledge about risk factors is needed.
Objectives
To predict psychological outcomes in relatives of patients at 90 days after death or discharge.
Methods
Prospective study on 4 ICUs in one German University hospital (04/2014 - 01/2015). The main relative of consecutive patients with severe sepsis were interviewed by phone at 90 days after patient discharge or death.Post traumatic stress symptoms (PTSS) were assessed by the Impact of Event Scale (IES), symptoms of anxiety and depression by the Hospital Anxiety and Depression Scale(HADS). Predictors were chosen based on literature,including demographic data, satisfaction with ICU care and information and experience of end-of-life care in the ICU. All patients’ health status before severe sepsis and survivors’ health status at 90 days were assessed by the relative using the EQ-5D questionnaire. A new item was introduced: feeling over strained by the ICU experience with rating on a scale from 1 to 10. Linear regression analyses were used to identify predictors in the full sample and among relatives of deceased and surviving patients.
Results
143 relatives (64% response rate) participated. Fifty (35%)patients died in the ICU, 78 (55%) were alive at the time of the interview. Among relatives, median [IQR] age was54 [47,63], 73% were female, 43% were spouses and 39%were children of the patient, 78% were legal proxies. After90 days, 66 relatives (47%) experienced symptoms of PTSS; 55 (39%) and 41 (29%) suffered from symptoms of anxiety and depression, respectively. IES, HADS anxiety or depression scores did not differ between relatives of deceased and surviving patients. By multivariate analyses no item on satisfaction with the ICU experience or the experience of end-of-life care reached significance. Female gender and lower education of relatives were risk factors for some psychological symptoms in the full sample and among relatives of deceased patients. Tracheostomy was a predictor of IES in the full sample (p=.004), treatment on a surgical ICU was a predictor of IES among relatives of deceased patients (p=.004). The degree of feeling over-strained by the ICU experience was a predictor of IES, HADS anxiety and depression in the full sample as well as in the subsamples of relatives of deceased and surviving patients (p≤.021).ThedifferenceinEQ-5Dhealthstatuspredicted IES and HADS depression among surviving patients (p≤.049).
Conclusions
Feeling overs trained during the ICU stay might be the strongest predictor of relatives’ psychological symptoms after three months. Tracheostomy in the ICU might be a predictor for PTSS. Both should be investigated in prospective longitudinal or interventional studies to better assess and prevent relatives’ psychological burden after their ICU experience.

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Objective

To evaluate patient post-intensive care syndrome (PICS-P) and caregiver burden 3 months after discharge from the Intensive Care Unit (ICU) and determine the impact of different components of PICS-P upon caregiver burden.
Design

A prospective observational study was conducted over 26 months (January 2013–February 2015).
Setting

Medical-surgical ICU and follow-up consultation in Portugal.
Patients or participants

Patients discharged after a minimum of 2 days in the ICU. Caregiver inclusion criteria: not paid, written and spoken Portuguese, and agreement to participate in the study.
Main variables of interest

In ICU: Patient gender, age, severity of illness (SAPS II) and length of ICU stay. At 3 months caregiver burden, physical (reduced mobility, weakness acquired in the ICU) and psychological components of PICS (anxiety, depression, post-traumatic stress disorder).
Results

A total of 168 caregivers completed the survey (response rate of 69%). A low degree of overburden was reported by 34.5% of caregivers, while 15.5% showed moderate to high levels of overburden.

Patient anxiety and depression 3 months after ICU discharge significantly influenced the presence of caregiver burden (p=0.030 vs p=0.008).

When physical components of PICS-P were evaluated, no influence on caregiver burden was observed. Patient demographics, severity of illness and length of stay also failed to influence caregiver burden.
Conclusions

The presence of psychological components of PICS-P 3 months after ICU seems to have a negative impact upon caregiver burden. On the other hand, physical problems showed no important impact upon caregiver overburden.

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It is now well established that many patients ‏and caregivers suffer physical, psychological ‏and social problems in the years ‏and months following critical care discharge ‏(Herridge et al. 2011). Similar to many centres, ‏our intensive care unit (ICU) had no follow-up ‏service available to support patients through this ‏difficult recovery period (Griffiths et al. 2006). ‏To understand how best to create a service ‏that was safe, effective and person-centred, ‏two members of our multidisciplinary team ‏(MDT) undertook research programmes to ‏help identify the problems that patients faced ‏after ICU and to help understand the context ‏for change (Quasim et al. 2015; McPeake et ‏al. 2016).

From this work, four main challenges were ‏identified:

There is minimal evidence of how and ‏when rehabilitation services should ‏be delivered (Mehlhorn et al. 2010), ‏despite an abundance of literature ‏describing the issues for ICU survivors ‏and their families.
The hardships facing ICU patients ‏are often not apparent to hospital ‏management. Readmissions to hospital, ‏increased general practitioner (family ‏physician) visitations and the increased ‏reliance on welfare benefits are distributed ‏amongst a variety of budgets, ‏which do not necessarily appear related ‏to an ICU admission.
Finding staff with the time and ability ‏to do something new that is different ‏from their traditional ICU role can be ‏problematic.
Finding physical space with a suitable ‏area to hold a rehabilitation programme ‏can be difficult.

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Critical care units’ nurses should seek to develop collaborative relationships with patients’ family members based
on their needs and help them to cope with their distress. Te objective of this study was to fnd out the perception of nurses on
needs of family members of patients admitted to critical care units.

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Introduction
Data on quality of life beyond 2 years after intensive care discharge are limited and we aimed to explore this area further. Our objective was to quantify quality of life and health utilities in the 5 years after intensive care discharge.

Methods
A prospective longitudinal cohort study in a University Hospital in the UK. Quality of life was assessed from the period before ICU admission until 5 years and quality adjusted life years calculated.

Results
300 level 3 intensive care patients of median age 60.5 years and median length of stay 6.7 days, were recruited. Physical quality of life fell to 3 months (P = 0.003), rose back to pre-morbid levels at 12 months then fell again from 2.5 to 5 years after intensive care (P = 0.002). Mean physical scores were below the population norm at all time points but the mean mental scores after 6 months were similar to those population norms. The utility value measured using the EuroQOL-5D quality of life assessment tool (EQ-5D) at 5 years was 0.677. During the five years after intensive care unit, the cumulative quality adjusted life years were significantly lower than that expected for the general population (P < 0.001).

Conclusions
Intensive care unit admission is associated with a high mortality, a poor physical quality of life and a low quality adjusted life years gained compared to the general population for 5 years after discharge. In this group, critical illness associated with ICU admission should be treated as a life time diagnosis with associated excess mortality, morbidity and the requirement for ongoing health care support.

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Introduction
To study the level and predictors of post traumatic stress, anxiety and depression symptoms in medical, surgical and trauma patients during the first year post intensive care unit (ICU) discharge.
Methods
Of 255 patients included, 194 participated at 12 months. Patients completed the Impact of Event Scale (IES), Hospital Anxiety and Depression Scale (HADS), Life Orientation Test (LOT) at 4 to 6 weeks, 3 and 12 months and ICU memory tool at the first assessment (baseline). Case level for post traumatic stress symptoms with high probability of a post traumatic stress disorder (PTSD) was ≥ 35. Case level of HADS-Anxiety or Depression was ≥ 11. Memory of pain during ICU stay was measured at baseline on a five-point Likert-scale (0-low to 4-high). Patient demographics and clinical variables were controlled for in logistic regression analyses.
Results
Mean IES score one year after ICU treatment was 22.5 (95%CI 20.0 to 25.1) and 27% (48/180) were above case level, IES ≥ 35. No significant differences in the IES mean scores across the three time points were found (P = 0.388). In a subgroup, 27/170 (16%), patients IES score increased from 11 to 32, P < 0.001. No differences in post traumatic stress, anxiety or depression between medical, surgical and trauma patients were found. High educational level (OR 0.4, 95%CI 0.2 to 1.0), personality trait (optimism) OR 0.9, 95%CI 0.8 to 1.0), factual recall (OR 6.6, 95%CI 1.4 to 31.0) and memory of pain (OR 1.5, 95%CI 1.1 to 2.0) were independent predictors of post traumatic stress symptoms at one year. Optimism was a strong predictor for less anxiety (OR 0.8, 0.8 to 0.9) and depression symptoms (OR 0.8, 0.8 to 0.9) after one year.

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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 behavioural 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.