Critical Care Medicine最新文献

Objectives: The aim of this study was to determine if being unable to stand at ICU discharge was associated with an increased probability of ICU readmission.

Design: A multicenter retrospective cohort study was conducted using the Toronto Intensive Care Observational Registry (iCORE) project.

Setting: Nine tertiary academic ICUs in Toronto, Canada, affiliated with the University of Toronto.

Patients: All patients admitted to ICUs participating in iCORE from September 2014 to January 2020 were included. Patients had to be mechanically ventilated for more than 4 hours to be included in iCORE. Exclusion criteria were death during the initial ICU stay, transfer to another institution not included in iCORE at ICU discharge, and a short ICU stay defined as less than 2 days.

Interventions: None.

Measurements and main results: The main exposure in this study was the inability of the patient to stand at ICU discharge, documented daily in the database within the ICU Mobility Scale. The primary outcome of this study was readmission to the ICU. After adjusting for potential confounders, being unable to stand at ICU discharge was associated with increased odds of readmission (odds ratio, 1.85; 95% CI, 1.31-2.62; p < 0.001).

Conclusions: In patients with an ICU stay of 2 days or more, being unable to stand at ICU discharge is associated with increased odds of readmission to the ICU.

Objectives: Older adults who survive critical illness are at risk for increased disability, limiting their independence and quality of life. We sought to evaluate whether the occurrence of symptoms that restrict activity, that is, restricting symptoms, is associated with increased disability following an ICU hospitalization.

Design: Prospective longitudinal study of community-living adults 70 years old or older who were interviewed monthly between 1998 and 2018.

Setting: South Central Connecticut, United States.

Patients: Two hundred fifty-one ICU admissions from 202 participants who were discharged alive from the hospital.

Interventions: None.

Measurements and main results: Occurrence of 15 restricting symptoms (operationalized as number of symptoms and presence of ≥ 2 symptoms) and disability in activities of daily living, instrumental activities of daily living, and mobility was ascertained during monthly interviews throughout the study period. We constructed multivariable Poisson regression models to evaluate the association between post-ICU restricting symptoms and subsequent disability over the 6 months following ICU hospitalization, adjusting for known risk factors for post-ICU disability including pre-ICU disability, frailty, cognitive impairment, mechanical ventilation, and ICU length of stay. The mean age of participants was 83.5 years (sd, 5.6 yr); 57% were female. Over the 6 months following ICU hospitalization, each unit increase in the number of restricting symptoms was associated with a 5% increase in the number of disabilities (adjusted rate ratio, 1.05; 95% CI, 1.04-1.06). The presence of greater than or equal to 2 restricting symptoms was associated with a 29% greater number of disabilities over the 6 months following ICU hospitalization as compared with less than 2 symptoms (adjusted rate ratio, 1.29; 95% CI, 1.22-1.36).

Conclusions: In this longitudinal cohort of community-living older adults, symptoms restricting activity were independently associated with increased disability after ICU hospitalization. These findings suggest that management of restricting symptoms may enhance functional recovery among older ICU survivors.

Objectives: Carbon monoxide (CO) poisoning can cause brain, heart, and kidney injuries. We aimed to determine the association of risks of all-cause and cause-specific mortality in patients with previous CO poisoning.

Design, setting, and patients: This population-based cohort study used data from the National Health Insurance Service database and the National Death Registry of Korea. Adult patients diagnosed with CO poisoning and controls between 2002 and 2020 were included. Patients were matched with controls on a 1:1 ratio, considering age, sex, insurance type, income level, residential location, smoking status, alcohol consumption, obesity status, medical and psychiatric illness history, and Charlson Comorbidity Index at the index date. The cohort was monitored from 2002 to 2022 or until death or emigration in terms of all-cause and cause-specific mortality.

Interventions: None.

Measurements and main results: A total of 48,600 patients with CO poisoning and matched controls were included. The cohort included 41.30% females, and the mean age was 48.05 years. Patients with CO poisoning exhibited a substantially elevated risk of all-cause mortality compared with those in the control group, with an adjusted hazard ratio (aHR) of 15.67 (95% CI, 12.58-19.51). The mortality associated with infectious (aHR, 6.71; 95% CI, 1.51-29.72), neoplasm/oncologic (aHR, 5.20; 95% CI, 3.39-7.99), endocrine (aHR, 13.44; 95% CI, 1.76-102.70), neurologic (aHR, 7.42; 95% CI, 2.91-18.90), cardiovascular (aHR, 8.97; 95% CI, 5.05-15.93), respiratory (aHR, 17.54; 95% CI, 5.48-56.17), and gastrointestinal (aHR, 24.72; 95% CI, 3.34-182.69) disorders was significantly greater in the former. Deaths due to external causes, including suicide, were significantly higher in the CO poisoning group (aHR, 50.07; 95% CI, 30.98-80.90).

Conclusions: Patients with CO poisoning exhibited a heightened risk of all-cause mortality compared with the matched controls. Additionally, the cause-specific mortality risk differed between the groups.

Objectives: To conduct a contemporary analysis of the association between family approach of medically suitable potential organ donors and race/ethnicity.

Design: Retrospective review of data collected prospectively by Organ Procurement Organizations (OPOs).

Setting: Ten OPOs representing eight regions of the Organ Procurement and Transplantation Network and 26% of all deceased donor organs recovered in the United States.

Subjects: All hospitalized patients on mechanical ventilation and referred to OPOs as potential donors from January 1, 2018, to December 31, 2022.

Interventions: None.

Measurements and main results: OPOs provided data on referral year, race, sex, donor registration status, screening determination, donation medical suitability, donation type (brain death, circulatory death), and family approach. We evaluated factors associated with family approach to discuss donation using descriptive statistics and multivariable logistic models. Of 255,429 total cases, 138,622 (54%) were screened-in for further evaluation, with variation by race/ethnicity (50% White, 60% Black, 69% Hispanic, and 60% Asian). Among those screened-in, 31,253 (23%) were medically suitable for donation, with modest variation by race/ethnicity (22% White, 26% Black, 23% Hispanic, and 21% Asian). Family approach rate by OPOs of medically suitable cases was 94% ( n = 29,315), which did not vary by race/ethnicity (94% White, 93% Black, 95% Hispanic, and 95% Asian). Family approach by OPOs was lower for circulatory death (95%) vs. brain death (97%) cases but showed minimal differences in approach rate based on race/ethnicity between medically suitable patients with different death pathways. In contrast, donor registration status of medically suitable potential donors was highly variable by race/ethnicity (37% overall; 45% White, 21% Black, 29% Hispanic, and 25% Asian). Multivariable models indicated no significant difference of family approach between White and Black (odds ratio [OR], 1.09; 95% CI, 0.95-1.24) or Asian (OR, 1.23; 95% CI, 0.95-1.60) patients.

Conclusions: Findings indicate racial equity in OPO family approach rates among patients who were medically suitable for organ donation.

Objectives: To characterize associations between race/ethnicity/sex, time-to-antibiotics, and mortality in patients with suspected sepsis or septic shock.

Design: Retrospective cohort study, with race/ethnicity/sex as the exposure, and time-to-antibiotics (relative to emergency department arrival) and in-hospital mortality as the outcome.

Setting: Five Massachusetts hospitals.

Patients: Forty-nine thousand six hundred nine adults admitted 2015-2022 with suspected sepsis or septic shock (blood cultures drawn and IV antibiotics administered within 24 hr of arrival, plus evidence of organ dysfunction for sepsis, and hypotension or lactate ≥ 4.0 mmol/L for septic shock).

Interventions: None.

Measurements and main results: Among included patients, 22,598 (46%) were women, 36,626 (75%) were White, and 4,483 (9.2%) were Black. Women had longer median time-to-antibiotics than men when presenting with either suspected sepsis (203 vs. 190 min) or septic shock (160 vs. 142 min). Differences in time-to-antibiotics for women vs. men persisted after adjusting for age, race, comorbidities, source of infection, and severity of illness (adjusted odds ratio [aOR] for 3-6 vs. < 3 hr; 1.16 [95% CI, 1.07-1.25] for sepsis and aOR, 1.09 [95% CI, 1.01-1.18] for septic shock). Median time-to-antibiotics was also longer for Black vs. White patients for both sepsis (215 vs. 194 min; aOR for 3-6 vs. < 3 hr; 1.24 [95% CI, 1.06-1.45]) and septic shock (median 159 vs. 148 min; aOR, 1.32 [95% CI, 1.12-1.55]). There was no association between race/ethnicity/sex and in-hospital mortality for sepsis without shock; however, women with septic shock had higher mortality (aOR, 1.16; 95% CI, 1.04-1.29) vs. men. Higher mortality for women with septic shock persisted when also adjusting for time-to-antibiotics (aOR, 1.16; 95% CI, 1.03-1.32).

Conclusions: In a large cohort of patients with sepsis, time-to-antibiotics was longer for both women and Black patients even after detailed risk-adjustment. Women with septic shock had higher adjusted in-hospital mortality than men, but this association was not moderated by time-to-antibiotics.

Objectives: This study aimed to demonstrate the impact of virtual visits on the satisfaction of family members and the anxiety and depression of patients in the ICU during the COVID-19 pandemic.

Design: A single-center, randomized controlled trial.

Setting: This study was conducted from July 2021 to May 2022, in the Seoul National University Hospital.

Patients: A total of 40 patients eligible for virtual visitation whose Richmond Agitation-Sedation Scale score was -2 or above were recruited and randomized into virtual visitation and usual care groups.

Interventions: Virtual visitation began on the first day after ICU admission and continued until ICU discharge, lasting for a maximum of 7 days.

Measurements and main results: The primary outcome was the satisfaction level of the family members with care and decision-making in the ICU, assessed using the Family Satisfaction-ICU (FS-ICU) 24-survey questionnaire. Secondary outcomes included patient anxiety and depression levels assessed using the Hospital Anxiety and Depression Scale (HADS), at the study enrollment after ICU admission and at the end of the study. After two patients were excluded due to clinical deterioration, 38 patients were ultimately analyzed, including 18 patients in the virtual visitation group and 20 patients in the usual care group. The FS-ICU 24 survey score was significantly higher in the virtual visitation group (89.1 ± 13.0 vs. 75.1 ± 17.7; p = 0.030). The reduction in HADS-Anxiety (59.4% vs. 15.39; p < 0.001) and HADS-Depression (64.5% vs. 24.2%; p < 0.001) scores between the two time points, from study enrollment after ICU admission to the end of the study was significantly larger in the virtual visitation group.

Conclusions: In the COVID-19 pandemic era, virtual visits to ICU patients helped reduce depression and anxiety levels of patients and increase the satisfaction of their family members. Enhancing access to virtual visits for family members and developing a consistent approach may improve the quality of care during another pandemic.

Objectives: To investigate the prevalence and association with mortality of inability to perform sit-to-stand independently in critically ill survivors 3 months following medical ICU (MICU) discharge.

Design: Prospective cohort study.

Setting: Six MICUs at a tertiary care hospital.

Patients: MICU survivors who could sit-to-stand independently before the index hospitalization.

Interventions: None.

Measurements and main results: Inability to sit-to-stand (yes/no) was measured at four points following MICU discharge: upon ICU discharge, 1, 2, and 3 months afterward. Mortality was evaluated at 6- and 12-month post-MICU discharge. Among 194 participants, 128 (66%) had inability to sit-to-stand upon MICU discharge. Recovery occurred, with rates decreasing to 50% at 1 month, 38% at 2 months, and 36% at 3 months post-MICU discharge, plateauing at 2 months. Inability to sit-to-stand at 3 months was significantly associated with 21% mortality at 12 months and a 4.2-fold increased risk of mortality (adjusted hazard ratio, 4.2; 95% CI, 1.61-10.99), independent of age, Sequential Organ Failure Assessment score, and ICU-acquired weakness. Notably, improvement in sit-to-stand ability, even from "totally unable" to "able with assistance," correlates with reduced mortality risk.

Conclusions: Inability to sit-to-stand affects about 36% of MICU survivors even at 3 months post-ICU discharge, highlighting rehabilitation challenges. Revisiting sit-to-stand ability post-ICU discharge is warranted. Additionally, using sit-to-stand as a screening tool for interventions to improve return of its function and mortality is suggested.

Objectives: Scarce research explores factors of concurrent psychologic distress (prolonged grief disorder [PGD], post-traumatic stress disorder [PTSD], and depression). This study models surrogates' longitudinal, heterogenous grief-related reactions and multidimensional risk factors drawing from the integrative framework of predictors for bereavement outcomes (intrapersonal, interpersonal, bereavement-related, and death-circumstance factors), emphasizing clinical modifiability.

Design: Prospective cohort study.

Setting: Medical ICUs of two Taiwanese medical centers.

Subjects: Two hundred eighty-eight family surrogates.

Interventions: None.

Measurements and main results: Factors associated with four previously identified PGD-PTSD-depressive-symptom states (resilient, subthreshold depression-dominant, PGD-dominant, and PGD-PTSD-depression concurrent) were examined by multinomial logistic regression modeling (resilient state as reference). Intrapersonal: Prior use of mood medications correlated with the subthreshold depression-dominant state. Financial hardship and emergency department visits correlated with the PGD-PTSD-depression concurrent state. Higher anxiety symptoms correlated with the three more profound psychologic-distress states (adjusted odds ratio [95% CI] = 1.781 [1.562-2.031] to 2.768 [2.288-3.347]). Interpersonal: Better perceived social support was associated with the subthreshold depression-dominant state. Bereavement-related: Spousal loss correlated with the PGD-dominant state. Death circumstances: Provision of palliative care (8.750 [1.603-47.768]) was associated with the PGD-PTSD-depression concurrent state. Surrogate-perceived quality of patient dying and death as poor-to-uncertain (4.063 [1.531-10.784]) correlated with the subthreshold depression-dominant state, poor-to-uncertain (12.833 [1.231-133.775]), and worst (12.820 [1.806-91.013]) correlated with the PGD-PTSD-depression concurrent state. Modifiable social-worker involvement (0.004 [0.001-0.097]) and a do-not-resuscitate order issued before death (0.177 [0.032-0.978]) were negatively associated with the PGD-PTSD-depression concurrent and the subthreshold depression-dominant state, respectively. Apparent unmodifiable buffering factors included surrogates' higher educational attainment, married status, and longer time since loss.

Conclusions: Surrogates' concurrent bereavement distress was positively associated with clinically modifiable factors: poor quality dying and death, higher surrogate anxiety, and palliative care-commonly provided late in the terminal-illness trajectory worldwide. Social-worker involvement and a do-not-resuscitate order appeared to mitigate risk.