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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.

Brief description of media:

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/µl), 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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In 226 consecutive critically ill primarily postoperative patients, we determined survival and quality of life, hospitalizaron charges, and consumption of blood and blood products. The patients were physiologically unstable and required intensive physician and nursing care. By one month, 123 patients had died (54 percent), 70 were still hospitalized, and 31 were home; only one of 103 survivors had fully recovered. By 12 months, 164 patients (73 per cent) had died, 10 were still hospitalized, and 51were home. Twenty-seven of 64 survivors had fully recovered.
Hospitalization charges averaged $14,304 per patient. The total charge for blood and blood fractions was $617,710—21 per cent of the total hospitalization charge; $ 515, 71 (83 per cent) of the blood charge went to 164 nonsurvivors, whereas $101,939 (17 per cent) went to the 62 survivors.
These data document the use of increasingly limited resources in the management of critically ill patients. The medical profession must make difficult decisions to allocate these resources effectively. (N Engl J Med 269:982-987,1976)

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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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The authors reviewed 16,301 citations, 1,908 abstracts and 193 full-text articles containing reference to PICS and selected 15 for detailed review. The review identified ICU acquired weakness, brain dysfunctions and mental health problems as key PICS symptoms.

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The prevalence of PTSD in ICU survivors is high and negatively impacts survivors’ HRQOL. Future studies should comprehensively address how patient-specific factors (e.g., pre-ICU psychopathology), ICU management factors (e.g., administration of sedatives), and ICU clinical factors (e.g., in-ICU delirium) relate to one another and to post-ICU PTSD. Clinicians caring for the growing population of ICU survivors should be aware of PTSD risk factors and monitor patients’ needs for early intervention.

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Our objective was to summarize and critically review data on the prevalence of posttraumatic stress disorder (PTSD) in general intensive care unit (ICU) survivors, risk factors for post-ICU PTSD, and the impact of post-ICU PTSD on health-related quality of life (HRQOL).

Brief description of media:

Post-traumatic stress disorder (PTSD) may develop after exposure to a life-threatening event or serious injury. Symptoms include recurring and intrusive memories, such as flashbacks, avoidance of reminders and persistent symptoms of anxiety or physiological arousal. Many factors are associated with the development of PTSD in intensive care unit (ICU) patients, including increased length of stay, and greater levels and longer duration of sedation. Patient-related factors associated with a higher risk of PTSD include younger age, female gender,previous psychological problems and recall of delusional memories from ICU. In contrast, the formation of even fragmented factual memories may reduce the risk of PTSD. Optimum, analgesia-based sedation may help patients to form factual memories of ICU, so possibly reducing the risk of PTSD. Patient diaries, written by health professionals and family members and close friends, may also support patients in coming to terms with traumatic, delusional memories, and so reduce their emotional and psychological symptoms. Following ICU discharge, validated screening tools such as ICU Memory and Post-traumatic Stress Syndrome 14-Questions Inventory can be used as part of routine follow-up to identify patients who may need referral for more specialist assessment of possible PTSD symptoms.

Brief description of media:

Post-traumatic stress disorder (PTSD) may develop after exposure to a life-threatening event or serious injury. Symptoms include recurring and intrusive memories, such as flashbacks, avoidance of reminders and persistent symptoms of anxiety or physiological arousal. Many factors are associated with the development of PTSD in intensive care unit (ICU) patients, including increased length of stay, and greater levels and longer duration of sedation. Patient-related factors associated with a higher risk of PTSD include younger age, female gender, previous psychological problems and recall of delusional memories from ICU. In contrast, the formation of even fragmented factual memories may reduce the risk of PTSD. Optimum, analgesia-based sedation may help patients to form factual memories of ICU, so possibly reducing the risk of PTSD. Patient diaries, written by health professionals and family members and close friends, may also support patients in coming to terms with traumatic, delusional memories, and so reduce their emotional and psychological symptoms. Following ICU discharge, validated screening tools such as ICU Memory and Post-traumatic Stress Syndrome 14-Questions Inventory can be used as part of routine follow-up to identify patients who may need referral for more specialist assessment of possible PTSD symptoms.

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A stay in the intensive care unit (ICU) can be traumatic. Patients are confronted with their own mortality. They are rolled in and hooked up to machines. Perhaps they are ventilated or catheterised. They might drift in and out of consciousness, seeing a different set of faces each time they wake. Confusion, sedation, and delirium make it difficult to communicate; intubation makes it impossible. Mysterious alarms ring at strange times. If the stay is long enough, there is likely to be a death, perhaps more than one, elsewhere in the ward. Hallucinations are common, some of which sound like a scene from a horror movie. “I have had patients talk about seeing blood dripping down the walls, or children with no faces”, said Joseph Bienvenu (Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA).
Symptoms of post-traumatic stress disorder (PTSD) vary from person to person, but typically include a combination of flashbacks and nightmares, avoiding reminders of the traumatic event, emotional numbing, and hyperarousal. Symptoms generally develop within a month, but some patients experience delayed onset. Around 60% of patients recover naturally within 5 years.

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Long-term cognitive impairment is common in survivors of critical illness. Little is known about the etiology of this serious complication. We sought to summarize current scientific knowledge about potentially modifiable risk factors during intensive care unit (ICU) treatment that may play a substantial role in the development of long-term cognitive impairment. All searches were run on October 1, 2017.The search strategy included Ovid MEDLINE, Ovid Embase, Ovid CDR, Cochrane Central Register of Controlled Trials and Database of Ab-stracts of Reviews of Effect, Scopus, and Web of Science, and included MeSH headings and keywords related to intensive care, critical care, and cognitive disorders. Searches were restricted to adult subjects. Inclusion required follow-up cognitive evaluation at least 2 months after ICU discharge. Studies assessing patients with cardiac arrest, traumatic brain injury, and cardiac surgery history were excluded. The search strategy resulted in 3180 studies. Of these, 28 studies (.88%) met our inclusion criteria and were analyzed. Delirium and duration of delirium were associated with long-term cognitive impairment after ICU admission in 6 of 9studies in which this factor was analyzed. Weaker and more inconsistent associations have been reported with hypoglycemia, hyperglycemia,fluctuations in serum glucose levels, and in-hospital acute stress symptoms.Instead, most of the studies did not find significant associations between long-term cognitive impairment and mechanical ventilation; use of sedatives, vasopressors, or analgesic medications; enteral feeding; hypoxia; extracorporeal membrane oxygenation; systolic blood pressure; pulse rate; or length of ICU stay. Prolonged delirium may be a risk factor for long-term cognitive impairment after critical illness, though this association has not been entirely consistent across studies. Other potentially preventable factors have not been shown to have strong or consistent associations with long-term cognitive dysfunction in survivors of critical illness.

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The practical considerations contained in this document are intended for use during the response to the coronavirus pandemic and may not be considered optimal outside of the pandemic. The pragmatic approaches outlined are intended to complement local protocols for nutritional care that may need to be adapted for use at this time. How challenges to providing nutritional care can be met will differ depending on local surge, availability and organisation of resources such as staff, skill mix and personal protective equipment (PPE).