scholarly journals Protocol for a randomised trial of an interprofessional team-delivered intervention to support surrogate decision-makers in ICUs

BMJ Open ◽  
2020 ◽  
Vol 10 (3) ◽  
pp. e033521
Author(s):  
Taylor Lincoln ◽  
Anne-Marie Shields ◽  
Praewpannarai Buddadhumaruk ◽  
Chung-Chou H Chang ◽  
Francis Pike ◽  
...  
Keyword(s):  
Family Support ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Maslach Burnout Inventory ◽  
Skills Training ◽  
Icu Stay ◽  
Surrogate Decision ◽  
The Impact

IntroductionAlthough shortcomings in clinician–family communication and decision making for incapacitated, critically ill patients are common, there are few rigorously tested interventions to improve outcomes. In this manuscript, we present our methodology for the Pairing Re-engineered Intensive Care Unit Teams with Nurse-Driven Emotional support and Relationship Building (PARTNER 2) trial, and discuss design challenges and their resolution.Methods and analysisThis is a pragmatic, stepped-wedge, cluster randomised controlled trial comparing the PARTNER 2 intervention to usual care among 690 incapacitated, critically ill patients and their surrogates in five ICUs in Pennsylvania. Eligible subjects will include critically ill patients at high risk of death and/or severe long-term functional impairment, their main surrogate decision-maker and their clinicians. The PARTNER intervention is delivered by the interprofessional ICU team and overseen by 4–6 nurses from each ICU. It involves: (1) advanced communication skills training for nurses to deliver support to surrogates throughout the ICU stay; (2) deploying a structured family support pathway; (3) enacting strategies to foster collaboration between ICU and palliative care services and (4) providing intensive implementation support to each ICU to incorporate the family support pathway into clinicians’ workflow. The primary outcome is surrogates’ ratings of the quality of communication during the ICU stay as assessed by telephone at 6-month follow-up. Prespecified secondary outcomes include surrogates’ scores on the Hospital Anxiety and Depression Scale, the Impact of Event Scale, the modified Patient Perception of Patient Centredness scale, the Decision Regret Scale, nurses’ scores on the Maslach Burnout Inventory, and length of stay during and costs of the index hospitalisation.We also discuss key methodological challenges, including determining the optimal level of randomisation, using existing staff to deploy the intervention and maximising long-term follow-up of participants.Ethics and disseminationWe obtained ethics approval through the University of Pittsburgh, Human Research Protection Office. The findings will be published in peer-reviewed journals.Trial registration numberNCT02445937

scholarly journals Development and preliminary evaluation of EMPOWER for surrogate decision-makers of critically ill patients

2021 ◽  
pp. 1-11
Author(s):  
Wendy G. Lichtenthal ◽  
Martin Viola ◽  
Madeline Rogers ◽  
Kailey E. Roberts ◽  
Lindsay Lief ◽  
...  
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Experiential Avoidance ◽  
Decision Makers ◽  
Post Intervention ◽  
Prolonged Grief ◽  
Surrogate Decision Makers ◽  
Surrogate Decision ◽  
Peritraumatic Distress

Abstract Objective The objectives of this study were to develop and refine EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), a brief manualized cognitive-behavioral, acceptance-based intervention for surrogate decision-makers of critically ill patients and to evaluate its preliminary feasibility, acceptability, and promise in improving surrogates’ mental health and patient outcomes. Method Part 1 involved obtaining qualitative stakeholder feedback from 5 bereaved surrogates and 10 critical care and mental health clinicians. Stakeholders were provided with the manual and prompted for feedback on its content, format, and language. Feedback was organized and incorporated into the manual, which was then re-circulated until consensus. In Part 2, surrogates of critically ill patients admitted to an intensive care unit (ICU) reporting moderate anxiety or close attachment were enrolled in an open trial of EMPOWER. Surrogates completed six, 15–20 min modules, totaling 1.5–2 h. Surrogates were administered measures of peritraumatic distress, experiential avoidance, prolonged grief, distress tolerance, anxiety, and depression at pre-intervention, post-intervention, and at 1-month and 3-month follow-up assessments. Results Part 1 resulted in changes to the EMPOWER manual, including reducing jargon, improving navigability, making EMPOWER applicable for a range of illness scenarios, rearranging the modules, and adding further instructions and psychoeducation. Part 2 findings suggested that EMPOWER is feasible, with 100% of participants completing all modules. The acceptability of EMPOWER appeared strong, with high ratings of effectiveness and helpfulness (M = 8/10). Results showed immediate post-intervention improvements in anxiety (d = −0.41), peritraumatic distress (d = −0.24), and experiential avoidance (d = −0.23). At the 3-month follow-up assessments, surrogates exhibited improvements in prolonged grief symptoms (d = −0.94), depression (d = −0.23), anxiety (d = −0.29), and experiential avoidance (d = −0.30). Significance of results Preliminary data suggest that EMPOWER is feasible, acceptable, and associated with notable improvements in psychological symptoms among surrogates. Future research should examine EMPOWER with a larger sample in a randomized controlled trial.

Impact of Hospitalized Nutritional Formula on Anthropometric, Clinical and Biochemical Indices among Egyptian Adult Cardio-Thoracic Critically Ill Patients: A Single Institutional Study

2021 ◽  
Vol 7 (1) ◽  
pp. 01-11
Author(s):  
Khalil NS
Keyword(s):  
Critically Ill ◽  
Clinical Data ◽  
Critically Ill Patients ◽  
Skin Color ◽  
Admission Time ◽  
Chest Disease ◽  
Disease Hospital ◽  
Biochemical Indices ◽  
The Impact

Background: Malnutrition is a common consequence notably in patients admitted to the intensive care unit. Aim of the study: was to assess the Impact of hospitalized nutritional formula on anthropometric, clinical and biochemical indices among Egyptian adult cardio-thoracic Critically Ill Patients on admission and discharge days. Methods: Totally, A convenient sample of 100 cardiothoracic patients was evaluated from admission to discharge in ICUs at Damietta Chest Disease Hospital in Egypt. The patients' anthropometric measurements, clinical data and biochemical indices were assessed As well, hospital diet prescription and intake was also evaluated. Results: High significant statistical difference patients' clinical data on admission and after one week such as body built (X2 = 52.6; p = 0.0), skin color (X2= 12.9; p = 0.02), skin turgor (X2= 13.19; p = 0.0), and occurrence of bed sore (X2= 27.7; p = 0.0). On the other hand, no significant statistical differences were found in the patients' weight and body mass index on admission and discharge (one week). Moreover, significant statistical differences were found in patients biochemical indices such as albumin (t= 3.03; p=0.003) and lymphocyte counts (3.74; p=0.000). So, the 88 % of patients showed decreased albumin after one week when compared to admission time. While, 10 % of patients showed increased lymphocytic count after one week of admission when compared to admission time. Conclusion and Recommendations: Clinical assessment, anthropometric, and biochemical indices are essential for evaluation, follow-up and management of cardiothoracic critically ill patients

Preserving fertility: using cyclophosphamide and other cytotoxics in young people

2019 ◽  
Vol 20 (2) ◽  
pp. 148-153
Author(s):  
David Ledingham ◽  
Michael Plant ◽  
Fayez Mustafa ◽  
Bhimanagouda Patil
Keyword(s):  
Young People ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Negative Impact ◽  
Cytotoxic Agents ◽  
Inflammatory Disorders ◽  
The Impact

Cytotoxic agents such as cyclophosphamide are infrequently used in neurological practice. When they are, it is commonly in critically ill patients or in those with refractory inflammatory disorders. Cyclophosphamide in particular has a well-recognised negative impact on both female and male long-term fertility. This article summarises the data with regards the impact of cytotoxics on long-term fertility and describes the current options to preserve fertility in these patients. We hope this will provide neurologists with a useful aid for counselling patients for whom they are considering these treatments.

scholarly journals Visfatin Serum Levels Predict Mortality in Critically Ill Patients

2018 ◽  
Vol 2018 ◽  
pp. 1-8 ◽  
Author(s):  
Alexander Koch ◽  
Ralf Weiskirchen ◽  
Alexander Krusch ◽  
Jan Bruensing ◽  
Lukas Buendgens ◽  
...  
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Serum Levels ◽  
Innate Immune ◽  
Medical Patients ◽  
Innate Immune Responses ◽  
Long Term Follow Up

The adipokine visfatin, also termed pre-B-cell colony-enhancing factor (PBEF), is mainly derived from adipose tissue but has been implicated in the regulation of innate immune responses. We hypothesized that visfatin could be a potential circulating biomarker in critical illness and sepsis. We therefore measured serum levels of visfatin in a cohort of 229 critically ill medical patients upon admission to the intensive care unit (ICU). In comparison to 53 healthy controls, visfatin levels were significantly elevated in medical ICU patients, especially in patients with sepsis. Visfatin serum concentrations were strongly associated with disease severity and organ failure but did not differ between patients with or without obesity or type 2 diabetes. Visfatin levels correlated with biomarkers of renal failure, liver dysfunction, and other adipokines (e.g., resistin, leptin, and adiponectin) in critically ill patients. High visfatin levels at ICU admission indicated an increased mortality, both at the ICU and during long-term follow-up of approximately two years. Our data therefore demonstrate that circulating visfatin is a valuable biomarker for risk and prognosis assessment in critically ill patients. Furthermore, visfatin seems to be involved in the pathogenesis of excessive systemic inflammation, supporting further research on visfatin as a therapeutic target.

A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care

2018 ◽  
pp. 235-240
Author(s):  
Joseph R. Guenzer ◽  
Andrew Vardanian
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Controlled Clinical Trial ◽  
Large Trial ◽  
Transfusion Threshold ◽  
Transfusion Requirements ◽  
Red Cell Transfusion ◽  
Study Intervention ◽  
The Impact

This chapter provides a summary of the landmark study known as the TRICC trial. Is a restrictive strategy of red-cell transfusion equivalent to a liberal transfusion strategy in critically ill patients? Starting with that question, the chapter describes the basics of the study, including funding, study location, who was studied, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism, and limitations. The chapter briefly reviews other relevant studies and information, discusses implications, and concludes with a relevant clinical case. Although this first large trial to examine the impact of transfusion thresholds on mortality in critically ill patients was underpowered, the trend toward decreased mortality in the restrictive group suggests that it is unlikely that the lower transfusion threshold subjects patients to increased harm. However, care must be taken in generalizing these results to cardiac surgery patients or to actively bleeding patients based on this study alone.

Critically Ill Patients Requiring Acute Renal Replacement Therapy Are at an Increased Risk of Long-Term Renal Dysfunction, but Rarely Receive Specialist Nephrology Follow-Up

Nephron ◽  
2015 ◽  
Vol 129 (3) ◽  
pp. 164-170 ◽  
Author(s):  
Christopher J. Kirwan ◽  
Mark J. Blunden ◽  
Hamish Dobbie ◽  
Ajith James ◽  
Ambika Nedungadi ◽  
...  
Keyword(s):  
Renal Replacement Therapy ◽  
Renal Dysfunction ◽  
Replacement Therapy ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Increased Risk

scholarly journals Long-Term Clinical Outcomes after Early Initiation of RRT in Critically Ill Patients with AKI

2017 ◽  
Vol 29 (3) ◽  
pp. 1011-1019 ◽  
Author(s):  
Melanie Meersch ◽  
Mira Küllmar ◽  
Christoph Schmidt ◽  
Joachim Gerss ◽  
Toni Weinhage ◽  
...  
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Primary Outcome ◽  
Early Stage ◽  
Early Initiation ◽  
Absolute Difference ◽  
Delayed Initiation ◽  
Major Adverse Kidney Events

Whether earlier initiation of RRT in critically ill patients with AKI can improve outcomes remains debated. We examined follow-up data from a large clinical trial to prospectively investigate the long-term outcomes associated with the timing of RRT initiation in such patients. We extended the follow-up of patients in the Early Versus Delayed Initiation of RRT in Critically Ill Patients with AKI (ELAIN) Trial from 90 days to 1 year after randomization for 230 (99.6%) patients. The primary outcome was a composite of major adverse kidney events (persistent renal dysfunction, dialysis dependence, and mortality) at 1 year. Secondary outcomes included inflammatory markers. Overall, 72 of 111 (64.9%) and 106 of 119 (89.1%) patients met the primary outcome in the early (stage 2 AKI) and delayed (stage 3 AKI) initiation groups, respectively (odds ratio [OR] with early initiation, 0.23; 95% confidence interval [95% CI], 0.11 to 0.45; P< 0.001). The early initiation group had a 1-year all-cause mortality rate (56 of 111 [50.2%]) significantly lower than that of the delayed initiation group (83 of 119 [69.8%]; absolute difference, −19.6%; 95% CI, −32.0% to −7.2%; P<0.01). After 1 year, 16 of 55 (29.1%) and 23 of 36 (63.9%) surviving patients in the early and delayed groups, respectively, failed to recover renal function (absolute difference, −34.8%; 95% CI, −54.6% to −15.0%; P=0.001). In conclusion, early initiation of RRT in these critically ill patients with AKI significantly reduced the occurrence of major adverse kidney events, reduced mortality, and enhanced renal recovery at 1 year.

scholarly journals Statins’ safety and impact on the clinical outcomes in COVID-19 critically ill patients: A Multicenter, Cohort Study

2021 ◽  
Author(s):  
Khalid Al Sulaiman ◽  
Ohoud Aljuhani ◽  
Ghazwa B. Korayem ◽  
Ali F. Altebainawi ◽  
Shmeylan Al Harbi ◽  
...  
Keyword(s):  
Cohort Study ◽  
Propensity Score ◽  
Hospital Mortality ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Hazard Ratio ◽  
Icu Stay ◽  
Markers Of Inflammation ◽  
The Impact ◽  
Statin Use

Abstract Purpose The complications of Severe Corona Virus Disease 2019 (COVID-19) are attributed to the overproduction of early response proinflammatory cytokines, causing a systemic hyperinflammatory state. Statins are potentially a potent adjuvant therapy in COVID-19 infection due to their pleiotropic and anti-inflammatory effects, which are independent of their cholesterol-lowering activity. This study investigates the impact of statin use on the outcome of critically ill patients with COVID-19. Methods A multicenter, retrospective cohort study of all adult critically ill patients with confirmed COVID-19 admitted to Intensive Care Units (ICUs) between March 1, 2020, and March 31, 2021. Eligible patients were classified into two groups based on statin use during ICU stay and were matched with a propensity score which was based on patient’s age and admission APACHE II and SOFA scores. The primary endpoint was in-hospital mortality. Other outcomes were considered secondary... Results A total of 1049 patients were eligible; 502 patients were included after propensity score matching (1:1 ratio). The 30-day (hazard ratio 0.75 (95% CI 0.58, 0.98), P = 0.03) and in-hospital mortality (hazard ratio 0.69 (95% CI 0.54, 0.89), P = 0.004) were significantly lower in patients who received statin therapy on multivariable cox proportional hazards regression analysis. Moreover, patients who received statin have a lower risk of hospital-acquired pneumonia (OR 0.48(95% CI 0.32, 0.69), P = < 0.001), lower levels of markers of inflammation on follow up and no increased risk of liver injury. Conclusion The use of statin during ICU stay in COVID-19 critically ill patients may have a beneficial role and survival benefits with a good safety profile.

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