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Background:
Psychologic symptoms of post traumatic stress disorder (PTSD) and depression are relatively common among family members of patients who die in the ICU. The patient-level risk factors for these family symptoms are not well understood but may help to target future interventions.
Methods:
We performed a cohort study of family members of patients who died in the ICU or within 30 h of ICU transfer. Outcomes included self-reported symptoms of PTSD and depression. Predictors included patient demographics and elements of palliative care.
Results:
Two hundred twenty-six patients had chart abstraction and family questionnaire data. Family members of older patients had lower scores for PTSD (P = .026). Family members that were present at the time of death (P = .021) and family members of patients with early family conferences (P = .012) reported higher symptoms of PTSD. When withdrawal of a ventilator was ordered, family members reported lower symptoms of depression (P = .033). There were no other patient characteristics or elements of palliative care associated with family symptoms.
Conclusions:
Family members of younger patients and those for whom mechanical ventilation is not withdrawn are at increased risk of psychologic symptoms and may represent an important group for intervention. Increased PTSD symptoms among family members present at the time of death may reflect a closer relationship with the patient or more involvement with the patient’s ICU care but also suggests that family should be offered the option of not being present.

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Complex trauma is still a relatively new field of psychology. Complex post-traumatic stress disorder (C-PTSD) results from enduring complex trauma.

Complex trauma is ongoing or repeated interpersonal trauma, where the victim is traumatized in captivity, and where there is no perceived way to escape. Ongoing child abuse is captivity abuse because the child cannot escape. Domestic violence is another example. Forced prostitution/sex trafficking is another.

Complex PTSD is a proposed disorder which is different to post-traumatic stress disorder. Many of the issues and symptoms endured by complex trauma survivors are outside of the list of symptoms within the (uncomplicated) PTSD diagnostic criterion. Complex PTSD does acknowledge and validate these added symptoms.

The impact of complex trauma is very different to a one time or short-lived trauma. The effect of repeated/ongoing trauma – caused by people – changes the brain, and also changes the survivor at a core level. It changes the way survivors view the world, other people and themselves in profound ways.

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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).

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Background: Several studies have described improved outcomes for HIV-infected patients admitted to the intensive care unit (ICU) since the introduction of highly active antiretroviral therapy (HAART). A study was undertaken to examine the outcome from the ICU for HIV-infected patients and to identify prognostic factors.
Methods: A retrospective study of HIV-infected adults admitted to a university affiliated hospital ICU between January 1999 and December 2005 was performed. Information was collected on patient demographics, receipt of HAART (no patient began HAART on the ICU), reason for ICU admission and hospital course. Outcomes were survival to ICU discharge and to hospital discharge.
Results: 102 patients had 113 admissions to the ICU; HIV infection was newly diagnosed in 31 patients. Survival (first episode ICU discharge and hospital discharge) was 77% and 68%, respectively, compared with 74% and 65% for general medical patients. ICU and hospital survival was 78% and 67% in those receiving HAART, and 75% and 66% in those who were not. In univariate analysis, factors associated with survival were: haemoglobin (OR = 1.25, 95% CI 1.03 to 1.51, for an increase of 1 g/dl), CD4 count (OR = 1.59, 95% CI 0.98 to 2.58, for a 10-fold increase in cells/ml), APACHE II score (OR = 0.51, 95% CI 0.29 to 0.90, for a 10 unit increase) and mechanical ventilation (OR = 0.29, 95% CI 0.10 to 0.83).
Conclusions: The outcome for HIV-infected patients admitted to the ICU was good and was comparable to that in general medical patients. More than a quarter of patients had newly diagnosed HIV infection. Patients receiving HAART did not have a better outcome.

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Background
Critical illness leading to prolonged length of stay (LOS) in an intensive care unit (ICU) is associated with significant mortality and resource utilization. This study assessed the independent effect of ICU LOS on in-hospital and long-term mortality after hospital discharge.
Methods
Clinical and mortality data of 22 298 patients, aged 16 yr and older, admitted to ICU between 1987 and 2002 were included in this linked-data cohort study. Cox's regression with restricted cubic spline function was used to model the effect of LOS on in-hospital and long-term mortality after adjusting for age, gender, acute physiology score (APS), maximum number of organ failures, era of admission, elective admission, Charlson's co-morbidity index, and diagnosis. The variability each predictor explained was calculated by the percentage of the χ2 statistic contribution to the total χ2 statistic.
Results
Most hospital deaths occurred within the first few days of ICU admission. Increasing LOS in ICU was not associated with an increased risk of in-hospital mortality after adjusting for other covariates, but was associated with an increased risk of long-term mortality after hospital discharge. The variability on the long-term mortality effect associated with ICU LOS (2.3%) appeared to reach a plateau after the first 10 days in ICU and was not as important as age (35.8%), co-morbidities (18.6%), diagnosis (10.9%), and APS (3.6%).
Conclusions
LOS in ICU was not an independent risk factor for in-hospital mortality, but it had a small effect on long-term mortality after hospital discharge after adjustment for other risk factors.

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A considerable number of patients undergoing allogeneic hematopoietic SCT (HSCT) develop post-transplant complications requiring intensive care unit (ICU) treatment. Whereas the indications and the outcome of ICU admission are well known, the risk factors leading to ICU admission are less well understood. We performed a retrospective single-center study on 250 consecutive HSCT patients analyzing the indications, risk factors and outcome of ICU admission. Of these 250 patients, 33 (13%) were admitted to the ICU. The most common indications for admission to the ICU were pulmonary complications (11, 33%), sepsis (8, 24%), neurological disorders (6, 18%) and cardiovascular problems (2, 6%). Acute GvHD and HLA mismatch were the only significant risk factors for ICU admission in multivariate analysis. Among patients admitted to the ICU, the number of organ failures correlated negatively with survival. Twenty-one (64%) patients died during the ICU stay and the 6-month mortality was 85% (27 out of 33). SAPS II score underestimated the mortality rate. In conclusion, acute GvHD and HLA mismatch were identified as risk factors for ICU admission following allogeneic HSCT. Both, short- and long-term survival of patients admitted to the ICU remains dismal and depends on the number of organ failures.

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In the UK, Scandinavia, and other European countries, patient diaries are being explored as a low cost technology to improve the quality of life after critical illness and mechanical ventilation (Combe, 2005; Egerod et al., 2007). Entries into the intensive care diary are made by nurses and in some countries also by relatives during the patient's stay. In other countries relatives are encouraged to write separate diaries (Gjengedal et al.,2010). The diary is written in everyday
language and contains daily entries on the current patient status and descriptions of situations and surroundings in which the patient might find recognition. The text is often supported by photos. It is written directly to the patient, using an empathetic and reflective style and therapeutic communication (Roulin et al., 2007).

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PHOENIX -- Nurse practitioner and physician assistant (NP/PA) care in the ICU could have a mortality benefit compared with care teams solely comprising resident physicians, a study showed.
Survival among patients in an ICU cared for by PA and acute care NP was 92.2% compared with 88.6% among those cared for in an adjacent ICU by a team of residents (P=0.047), with all other staffing and resources equal, Joe Keller, PA-c, of the Cleveland Clinic, and colleagues found.

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This is a training manual for physicians, nurses and other healthcare professionals who wish to use the Confusion Assessment Method for the ICU (CAM-ICU). The CAM-ICU is a delirium monitoring instrument for ICU patients. A complete detailed explanation of how to use the CAM-ICU, as well as answers to frequently asked questions and case studies are provided in this manual.

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Objective—To evaluate the association between length of ICU stay and 1-year mortality for elderly patients who survived to hospital discharge in the United States.
Design and Setting—Retrospective cohort study of a random sample of Medicare beneficiaries who survived to hospital discharge, with 1 and 3-year follow-up, stratified by the number of days of intensive care and with additional stratification based on receipt of mechanical ventilation.
Interventions—None
Patients—The cohort included 34,696 Medicare beneficiaries older than 65 years who received intensive care and survived to hospital discharge in 2005.
Measurements and Main Results—Among 34,696 patients who survived to hospital
discharge, the mean ICU length of stay was 3.4 (±4.5) days. 88.9% of patients were in the ICU for 1–6 days, representing 58.6% of ICU bed-days. 1.3% of patients were in the ICU for 21+ days, but these patients used 11.6% of bed-days. The percentage of mechanically ventilated patients increased with increasing length of stay (6.3% for 1–6 days in the ICU and 71.3% for 21+ days). One-year mortality was 26.6%, ranging from 19.4% for patients in the ICU for one day, up to 57.8% for patients in the ICU for 21+ days. For each day beyond seven days in the ICU, there was an increased odds of death by 1-year of 1.04 (95% CI 1.03–1.05) irrespective of the need for mechanical ventilation.
Conclusions—Increasing ICU length of stay is associated with higher 1-year mortality for both mechanically ventilated and non-mechanically ventilated patients. No specific cut-off was associated with a clear plateau or sharp increase in long-term risk.

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The ICU can be an intimidating and stressful environment. This manual is intended to help support medical students, interns, and residents working in the ICU. Please be mindful that this manual is a guide for care in the ICU. Clinical treatment decisions are variable and nuanced depending on patient, nursing, and attending factors.

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Background: Delirium affects nearly 70% of older adults hospitalized in the intensive care unit (ICU), and many of those will be left with persistent cognitive impairment or dementia. There are no effective and scalable recovery models to remediate ICU-acquired cognitive impairment and its attendant elevated risk for dementia or Alzheimer disease (AD). The Improving Recovery and Outcomes Every Day after the ICU (IMPROVE) trial is an ongoing clinical trial which evaluates the efficacy of a combined physical exercise and cognitive training on cognitive function among ICU survivors 50 years and older who experienced delirium during an ICU stay. This article describes the study protocol for IMPROVE.
Methods: IMPROVE is a four-arm, randomized controlled trial. Subjects will be randomized to one of four arms: cognitive training and physical exercise; cognitive control and physical exercise; cognitive training and physical exercise control; and
cognitive control and physical exercise control. Facilitators administer the physical exercise and exercise control interventions in individual and small group formats by using Internet-enabled video conference. Cognitive training and control interventions are also facilitator led using Posit Science, Inc. online modules delivered in individual and small group format directly into the participants’ homes. Subjects complete cognitive assessment, mood questionnaires, physical performance batteries, and quality of life scales at baseline, 3, and 6 months. Blood samples will also be taken at baseline and 3 months to measure pro-inflammatory cytokines and acute-phase reactants; neurotrophic factors; and markers of glial dysfunction and astrocyte activation.
Discussion: This study is the first clinical trial to examine the efficacy of combined physical and cognitive exercise on
cognitive function in older ICU survivors with delirium. The results will provide information about potential synergistic
effects of a combined intervention on a range of outcomes and mechanisms of action.