Brief description of media:

Background: Although the epidemiology of acute kidney injury (AKI) has been well described, less is known about recurrent AKI (r-AKI). We undertook a systematic review to identify incidence, risk factors, and outcomes of r-AKI. Methods: MEDLINE, EMBASE, CINAHL, Cochrane, Web of Science were searched, from inception to December 2017, for quantitative studies on adults with AKI, where follow-up included ­reporting of r-AKI. Two reviewers independently identified studies and assessed study quality. Summary: From 2,824 citations, 10 cohort studies met inclusion criteria (total patients n = 538,667). There were 2 distinct set of studies; 4 studies assessed r-AKI within the same hospital admission (most were intensive care unit [ICU] patients) and 6 studies assessed postdischarge r-AKI. The median percentage of people developing r-AKI within the same hospital admission was 23.4% (IQR 20.3–27.2%) and postdischarge r-AKI was 31.3% (IQR 26.4–33.7%). A higher Acute Physiology and Chronic Health Evaluation score was associated with increased risk of r-AKI within the same hospital admission in ICU patients. Cardiovascular disease and AKI severity were associated with increased risk of postdischarge r-AKI. R-AKI (within same admission and postdischarge) was associated with worse survival. It was not possible to pool results due to methodological differences across studies, such as varying definitions for AKI and r-AKI, varying length of follow-up and effect measures. Key messages: More representative population-based studies with robust assessment of predictors and consensus definition of r-AKI are needed to identify risk factors and develop risk stratification tools to reduce recurrence and improve outcomes. Systematic Review Registration: CRD42017082668.

Brief description of media:

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.

Brief description of media:

Purpose:Post-traumatic stress disorder has been reported in survivors of critical illness. The aim of this study was to investigate the predictors of post-traumatic stress disorder in survivors of critical illness.Materials and methods:Patients attending the intensive care unit (ICU) follow-up clinic completed the UK-Post-Traumatic Stress Syndrome 14-Questions Inventory and data was collected from their medical records. Predictors investigated included age, gender, Apache II score, ICU length of stay, pre-illness psychopathology; delirium and benzodiazepine administration during ICU stay and delusional memories of the ICU stay following discharge.Results:A total of 198 patients participated, with 54 (27%) patients suffering with post-traumatic stress disorder.On multivariable logistic regression, the significant predictors of post-traumatic stress disorder were younger age,lower Apache II score, pre-illness psychopathology and delirium during the ICU stay.Conclusions:The predictors of post-traumatic stress disorder in this study concur with previous research however a lower Apache II score has not been previously reported.

Brief description of media:

Background: Pregnancy is considered to be an important risk factor for severe complications following influenza virus infection. As a consequence, WHO recommendations prioritize pregnant women over other risk groups for influenza vaccination. However, the risk associated with pregnancy has not been systematically quantified.

Purpose: Systematic review and meta-analysis of observational studies that reported on pregnancy as a risk factor for severe outcomes from influenza virus infection.

Data source: MEDLINE, EMBASE, CINAHL, and CENTRAL up to April 2014.

Data selection: Studies reporting on outcomes in pregnant women with influenza in comparison to non-pregnant patients with influenza. Outcomes included community-acquired pneumonia, hospitalization, admission to intensive care units (ICU), ventilatory support, and death.

Data extraction: Two reviewers conducted independent screening and data extraction. A random effects model was used to obtain risk estimates. Ecological studies were summarized descriptively.

Data synthesis: A total of 142 non-ecological and 10 ecological studies were included. The majority of studies (n=136, 95.8%) were conducted during the 2009 influenza A (pH1N1) pandemic. There was a higher risk for hospitalization in pregnant versus non-pregnant patients infected with influenza (odds ratio [OR] 2.44, 95% CI 1.22-4.87), but no significant difference in mortality (OR 1.04, 95% CI 0.81-1.33) or other outcomes. Ecologic studies confirmed the association between hospitalization risk and pregnancy and 4 of 7 studies reported higher mortality rates in pregnant women.

Limitations: No studies were identified in which follow-up began prior to contact with the healthcare system and lack of adjustment for confounding factors.

Conclusions: We found that influenza during pregnancy resulted in a higher risk of hospital admission than influenza infection in non-pregnant individuals, but that the risk of mortality following influenza was similar in both pregnant and non-pregnant individuals.

Brief description of media:

Background

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) account for one‐quarter of cases of acute respiratory failure in intensive care units (ICUs). A third to half of patients will die in the ICU, in hospital or during follow‐up. Mechanical ventilation of people with ALI/ARDS allows time for the lungs to heal, but ventilation is invasive and can result in lung injury. It is uncertain whether ventilator‐related injury would be reduced if pressure delivered by the ventilator with each breath is controlled, or whether the volume of air delivered by each breath is limited.
Objectives

To compare pressure‐controlled ventilation (PCV) versus volume‐controlled ventilation (VCV) in adults with ALI/ARDS to determine whether PCV reduces in‐hospital mortality and morbidity in intubated and ventilated adults.
Search methods

In October 2014, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Isssue 9), MEDLINE (1950 to 1 October 2014), EMBASE (1980 to 1 October 2014), the Latin American Caribbean Health Sciences Literature (LILACS) (1994 to 1 October 2014) and Science Citation Index‐Expanded (SCI‐EXPANDED) at the Institute for Scientific Information (ISI) Web of Science (1990 to 1 October 2014), as well as regional databases, clinical trials registries, conference proceedings and reference lists.
Selection criteria

Randomized controlled trials (RCTs) and quasi‐RCTs (irrespective of language or publication status) of adults with a diagnosis of acute respiratory failure or acute on chronic respiratory failure and fulfilling the criteria for ALI/ARDS as defined by the American‐European Consensus Conference who were admitted to an ICU for invasive mechanical ventilation, comparing pressure‐controlled or pressure‐controlled inverse‐ratio ventilation, or an equivalent pressure‐controlled mode (PCV), versus volume‐controlled ventilation, or an equivalent volume‐controlled mode (VCV).
Data collection and analysis

Two review authors independently screened and selected trials, assessed risk of bias and extracted data. We sought clarification from trial authors when needed. We pooled risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data with their 95% confidence intervals (CIs) using a random‐effects model. We assessed overall evidence quality using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach.
Main results

We included three RCTs that randomly assigned a total of 1089 participants recruited from 43 ICUs in Australia, Canada, Saudi Arabia, Spain and the USA. Risk of bias of the included studies was low. Only data for mortality and barotrauma could be combined in the meta‐analysis. We downgraded the quality of evidence for the three mortality outcomes on the basis of serious imprecision around the effect estimates. For mortality in hospital, the RR with PCV compared with VCV was 0.83 (95% CI 0.67 to 1.02; three trials, 1089 participants; moderate‐quality evidence), and for mortality in the ICU, the RR with PCV compared with VCV was 0.84 (95% CI 0.71 to 0.99; two trials, 1062 participants; moderate‐quality evidence). One study provided no evidence of clear benefit with the ventilatory mode for mortality at 28 days (RR 0.88, 95% CI 0.73 to 1.06; 983 participants; moderate‐quality evidence). The difference in effect on barotrauma between PCV and VCV was uncertain as the result of imprecision and different co‐interventions used in the studies (RR 1.24, 95% CI 0.87 to 1.77; two trials, 1062 participants; low‐quality evidence). Data from one trial with 983 participants for the mean duration of ventilation, and from another trial with 78 participants for the mean number of extrapulmonary organ failures that developed with PCV or VCV, were skewed. None of the trials reported on infection during ventilation or quality of life after discharge.
Authors' conclusions

Currently available data from RCTs are insufficient to confirm or refute whether pressure‐controlled or volume‐controlled ventilation offers any advantage for people with acute respiratory failure due to acute lung injury or acute respiratory distress syndrome. More studies including a larger number of people given PCV and VCV may provide reliable evidence on which more firm conclusions can be based.

Brief description of media:

Summary Background: To date, 750000 patients with COVID-19 worldwide have required mechanical ventilation and thus are at high risk of acute brain dysfunction (coma and delirium). We aimed to investigate the prevalence of delirium and coma, and risk factors for delirium in critically ill patients with COVID-19, to aid the development of strategies to mitigate delirium and associated sequelae.
Methods: This multi-centre cohort study included 69 adult intensive care units (ICUs), across 14 countries. We included all patients (aged ≥18 years) admitted to participating ICUs with severe acute respiratory syndrome coronavirus 2 infection before April 28, 2020. Patients who were moribund or had life-support measures withdrawn within 24 h of ICU admission, prisoners, patients with pre-existing mental illness, neurodegenerative disorders, congenital or acquired brain damage, hepatic coma, drug overdose, suicide attempt, or those who were blind or deaf were excluded. We collected de-identified data from electronic health records on patient demographics, delirium and coma assessments, and management strategies for a 21-day period. Additional data on ventilator support, ICU length of stay, and vital status was collected for a 28-day period. The primary outcome was to determine the prevalence of delirium and coma and to investigate any associated risk factors associated with development of delirium the next day. We also investigated predictors of number of days alive without delirium or coma. These outcomes were investigated using multivariable regression.
Findings: Between Jan 20 and April 28, 2020, 4530 patients with COVID-19 were admitted to 69 ICUs, of whom 2088 patients were included in the study cohort. The median age of patients was 64 years (IQR 54 to 71) with a median Simplified Acute Physiology Score (SAPS) II of 40·0 (30·0 to 53·0). 1397 (66·9%) of 2088 patients were invasively mechanically ventilated on the day of ICU admission and 1827 (87·5%) were invasively mechanical ventilated at some point during hospitalisation. Infusion with sedatives while on mechanical ventilation was common: 1337 (64·0%) of 2088 patients were given benzodiazepines for a median of 7·0 days (4·0 to 12·0) and 1481 (70·9%) were given propofol for a median of 7·0 days (4·0 to 11·0). Median Richmond Agitation–Sedation Scale score while on invasive mechanical ventilation was –4 (–5 to –3). 1704 (81·6%) of 2088 patients were comatose for a median of 10·0 days (6·0 to 15·0) and 1147 (54·9%) were delirious for a median of 3·0 days (2·0 to 6·0). Mechanical ventilation, use of restraints, and benzodiazepine, opioid, and vasopressor infusions, and antipsychotics were each associated with a higher risk of delirium the next day (all p≤0·04), whereas family visitation (in person or virtual) was associated with a lower risk of delirium (p<0·0001). During the 21-day study period, patients were alive without delirium or coma for a median of 5·0 days (0·0 to 14·0). At baseline, older age, higher SAPS II scores, male sex, smoking or alcohol abuse, use of vasopressors on day 1, and invasive mechanical ventilation on day 1 were independently associated with fewer days alive and free of delirium and coma (all p<0·01). 601 (28·8%) of 2088 patients died within 28 days of admission, with most of those deaths occurring in the ICU.
Interpretation: Acute brain dysfunction was highly prevalent and prolonged in critically ill patients with COVID-19. Benzodiazepine use and lack of family visitation were identified as modifiable risk factors for delirium, and thus these data present an opportunity to reduce acute brain dysfunction in patients with COVID-19.

Brief description of media:

As more patients are surviving intensive care, mental health concerns in survivors have become a research priority. Among these, post-traumatic stress disorder (PTSD) can have an important impact on the quality of life of critical care survivors. However, data on its burden are conflicting. Therefore, this systematic review and meta-analysis aimed to evaluate the prevalence of PTSD symptoms in adult critical care patients after intensive care unit (ICU) discharge.

Brief description of media:

In the early days of caring for critically ill patients with acute respiratory distress syndrome, sepsis or multiple organ failure, we were grateful when they survived their illness. We used any interventions we could think of to increase the likelihood of survival. We didn’t really think about what came after patients’ intensive care unit (ICU) experience; we were just happy they survived. However, we came to find out that despite our best efforts, these patients had a high risk of developing delirium and post-discharge sequelae.

Brief description of media:

Prevention of cardiac arrest is the first link in the Chain of Survival. This section of the Resuscitation Council UK guidelines stresses the importance of preventing cardiac arrest in all age groups, and the decision-making process when cardiopulmonary resuscitation (CPR) is inappropriate. This update is based on the European Resuscitation Council Guidelines 2015, and includes updates based on NICE Clinical Guideline 50, and the guidance from the British Medical Association (BMA), Resuscitation Council UK, and the Royal College of Nursing (RCN) on decisions relating to CPR. The General Medical Council publication, ‘Treatment and care towards the end of life: good practice in decision making’, also includes advice on decisions relating to CPR.

Brief description of media:

The purpose of this study is to:•determine effect size of the Sensation Awareness Focused Training (SĀF-T) intervention on Post Intensive Care Syndrome (PICS) in Family Members, specifically spouses, and•explore if the effect of SĀF-T and sleep/rest are related.

Brief description of media:

Post Intensive Care Syndrome-Family (PICS-F) refers to acute and chronic psychological effects of critical illness on family members of patients in intensive care units (ICU). Evidence about the increase and persistence of PICS-F warrants the need for prevention interventions. This study evaluated the feasibility of providing Sensation Awareness Focused Training (SĀF-T) during the ICU stay for spouses of mechanically ventilated patients. Methods: A randomized controlled trial of SĀF-T versus a control group was conducted (n=10) to assess safety, acceptability, feasibility, and effect size of the intervention on PICS-F symptoms. Symptoms assessed as outcome measures included stress, anxiety, depression, post-traumatic stress disorder, and sleep efficiency. Those randomly assigned to SĀF-T received one session daily over 3-days in the ICU. Repeated measures (day 1, day 3, day 30, and day 90) of PICS-F symptoms in both groups were analyzed. Results: Mean age was 58 ± 12 years; 70% were female. Feasibility success criteria were met in weekly recruitment (8 ± 3.5), enrollment rate (67%), SĀF-T acceptability (100% of doses received, no adverse events) with significantly lower post SĀF-T stress levels (p<.05) compared to pre SĀF-T stress levels, ActiWatch acceptability rate (90% agreed to wear, no adverse events) with no significant difference in sleep efficiency between groups (p>.05), and repeated measures completion rate (>90%). Conclusions: This study provided guidance for modifications to protocol outcome measures and evidence of a large effect size, which will inform a larger clinical trial to assess the effectiveness of the SĀF-T intervention in reducing PICS-F.

Brief description of media:

More than 5.7 million patients are admitted to intensive care units (ICU) each year in the United States. Critical illness is a family crisis. There is strong evidence that family distress in response to critical illness does not disappear after ICU discharge. The Society of Critical Care Medicine has identified a cluster of complications that occur in family members of ICU patients as Post Intensive Care Syndrome-Family (PICS-F). PICS in family members of adult ICU survivors include symptoms of ongoing anxiety, depression, and post-traumatic stress disorder (PTSD). Data suggest that 70% of family members have symptoms of ongoing anxiety, and 33% have symptoms of depression and PTSD, which can persist for ≥4 years. Moreover, symptoms of anxiety, depression, and PTSD are higher and persist longer in family members than in adult ICU survivors. Because PICS-F occurs with greater frequency in spouses and surrogate health decision-makers, this study focused on participants whom are spouses of mechanically ventilated critically ill adults (typically sedated and unable to make their own health decisions).