Determinants of gait independence after mechanical ventilation in the intensive care unit: a Japanese multicenter retrospective exploratory cohort study

Abstract Purpose Gait independence is one of the most important factors related to returning home from the hospital for patients treated in the intensive care unit (ICU), but the factors affecting gait independence have not been clarified. This study aimed to determine the factors affecting gait independence at hospital discharge using a standardized early mobilization protocol that was shared by participating hospitals. Materials and methods Patients who entered the ICU from January 2017 to March 2018 were screened. The exclusion criteria were mechanical ventilation < 48 hours, age < 18, loss of gait independence before hospitalization, being treated for neurological issues, unrecoverable disease, unavailability of continuous data, and death during ICU stay. Basic attributes, such as age, ICU length of stay, information on early mobilization while in the ICU, Medical Research Council (MRC) sum-score at ICU discharge, incidence of ICU-acquired weakness (ICU-AW) and delirium, and the degree of gait independence at hospital discharge, were collected. Gait independence was determined using a mobility scale of the Barthel Index, and the factors that impaired gait independence at hospital discharge were investigated using a Cox proportional hazard regression analysis. Results One hundred thirty-two patients were analyzed. In the univariate analysis, age, APACHE II score, duration of mechanical ventilation, ICU length of stay, incidence of delirium, and MRC sum-score at ICU discharge were extracted as significant. In the multivariate analysis, age (p = 0.014), MRC sum-score < 48 (p = 0.021), and delirium at discharge from ICU (p < 0.0001) were extracted as significant variables. Conclusions We found that age and incidence of ICU-AW and delirium were significantly related to impaired gait independence at hospital discharge.

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Early mobilization is associated with decreased mechanical ventilation and ICU length of stay following cardiac surgery

Health & Research Journal ◽

10.12681/healthresj.28161 ◽

2021 ◽

Vol 7 (4) ◽

pp. 184

Author(s):

Vasiliki Raidou ◽

Stavros Dimopoulos ◽

Foteini Chatzivasiloglou ◽

Christos Kourek ◽

Vasiliki Tsagari ◽

...

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Cardiac Surgery ◽

Intensive Care ◽

Length Of Stay ◽

Medical Records ◽

Early Mobilization ◽

Icu Stay ◽

Icu Length Of Stay ◽

Icu Discharge

Background: Early mobilization of the Intensive Care Unit (ICU) patients improves muscle strength and functional capacity. It has been demonstrated that prevents Intensive Care Unit Acquired Weakness (ICUAW) and accelerates ICU discharge. However, data on mobilization early after cardiac surgery are inadequate. This study aimed to record early mobilization and investigates the association with ICU findings in cardiac surgery patients.Material and Methods: In this observational study, 165 patients after cardiac surgery were enrolled. Of these, 159 were assessed for early mobilization and mobilization status during ICU stay. Mobilization practices were recorded from 1st post ICU admission and every 48 h until 7th day. The duration of mechanical ventilation (MV) support, ICU length of stay and clinical outcome were recorded from medical records registration. Results: Early mobilization consisted of active and passive limb mobilization, sitting in bed and transferring from bed to chair. The proportion of patients mobilized, was 18% (n = 29/159) on day 1, 53% (n = 46/87) on day 3, 54% (n = 22/41) on day 5 and 62% (n = 15/24) on day 7. ICU length of stay was reduced for mobilized patients (n = 29) on day 1 compared to non-mobilized ones (24 ± 10 vs 47 ± 73 h respectively, P = 0.001). The duration of MV was shorter in mobilized patients on day 3 (n =46) compared to bedridden, (18 ± 9 vs 23 ± 30 h respectively, P = 0.01).Conclusions: Early mobilization after cardiac surgery was found to be low with a significant trend to increase over ICU stay. It is also associated with a reduced duration of MV and ICU length of stay.

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Analgosedation: The use of Fentanyl Compared to Hydromorphone

The Journal of Critical Care Medicine ◽

10.2478/jccm-2021-0026 ◽

2021 ◽

Vol 7 (3) ◽

pp. 192-198

Author(s):

Hahnl Choi ◽

Sara Radparvar ◽

Samuel L. Aitken ◽

Jerry Altshuler

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Critical Care ◽

Intensive Care ◽

Length Of Stay ◽

Continuous Infusion ◽

Surgical Intensive Care Unit ◽

Icu Length Of Stay ◽

Primary Endpoints ◽

Fentanyl Group

Abstract Background: The 2018 Society of Critical Care Medicine guidelines on the “Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU” advocate for protocol-based analgosedation practices. There are limited data available to guide which analgesic to use. This study compares outcomes in patients who received continuous infusions of fentanyl or hydromorphone as sedative agents in the intensive care setting. Methods: This retrospective cohort study evaluated patients admitted into the medical intensive care unit, the surgical intensive care unit, and the cardiac intensive care unit from April 1, 2017, to August 1, 2018, who were placed on continuous analgesics. Patients were divided according to receipt of fentanyl or hydromorphone as a continuous infusion as a sedative agent. The primary endpoints were ICU length of stay and time on mechanical ventilation. Results: A total of 177 patients were included in the study; 103 received fentanyl as a continuous infusion, and 74 received hydromorphone as a continuous infusion. Baseline characteristics were similar between groups. Patients in the hydromorphone group had deeper sedation targets. Median ICU length of stay was eight days in the fentanyl group compared to seven days in the hydromorphone group (p = 0.11) and median time on mechanical ventilation was 146.47 hours in the fentanyl group and 122.33 hours in the hydromorphone group (p = 0.31). There were no statistically significant differences in the primary endpoints of ICU length of stay and time on mechanical ventilation between fentanyl and hydromorphone for analgosedation purposes. Conclusion: No statistically significant differences were found in the primary endpoints studied. Patients in the hydromorphone group required more tracheostomies, restraints, and were more likely to have a higher proportion of Critical Care Pain Observation Tool (CPOT) scores > 2.

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Outcomes and Timing of Bedside Percutaneous Tracheostomy of COVID-19 Patients over a Year in the Intensive Care Unit

Journal of Clinical Medicine ◽

10.3390/jcm10153335 ◽

2021 ◽

Vol 10 (15) ◽

pp. 3335

Author(s):

Nardi Tetaj ◽

Micaela Maritti ◽

Giulia Stazi ◽

Maria Marini ◽

Daniele Centanni ◽

...

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Length Of Stay ◽

Percutaneous Tracheostomy ◽

Medical Team ◽

Early Group ◽

Icu Length Of Stay ◽

Anesthetic Drugs ◽

Late Group

Background: The benefits and timing of percutaneous dilatational tracheostomy (PDT) in Intensive Care Unit (ICU) COVID-19 patients are still controversial. PDT is considered a high-risk procedure for the transmission of SARS-CoV-2 to healthcare workers (HCWs). The present study analyzed the optimal timing of PDT, the clinical outcomes of patients undergoing PDT, and the safety of HCWs performing PDT. Methods: Of the 133 COVID-19 patients who underwent PDT in our ICU from 1 April 2020 to 31 March 2021, 13 patients were excluded, and 120 patients were enrolled. A trained medical team was dedicated to the PDT procedure. Demographic, clinical history, and outcome data were collected. Patients who underwent PDT were stratified into two groups: an early group (PDT ≤ 12 days after orotracheal intubation (OTI) and a late group (>12 days after OTI). An HCW surveillance program was also performed. Results: The early group included 61 patients and the late group included 59 patients. The early group patients had a shorter ICU length of stay and fewer days of mechanical ventilation than the late group (p < 0.001). On day 7 after tracheostomy, early group patients required fewer intravenous anesthetic drugs and experienced an improvement of the ventilation parameters PaO2/FiO2 ratio, PEEP, and FiO2 (p < 0.001). No difference in the case fatality ratio between the two groups was observed. No SARS-CoV-2 infections were reported in the HCWs performing the PDTs. Conclusions: PDT was safe and effective for COVID-19 patients since it improved respiratory support parameters, reduced ICU length of stay and duration of mechanical ventilation, and optimized the weaning process. The procedure was safe for all HCWs involved in the dedicated medical team. The development of standardized early PDT protocols should be implemented, and PDT could be considered a first-line approach in ICU COVID-19 patients requiring prolonged mechanical ventilation.

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Low-PEEP Mechanical Ventilation and P/F Ratio Evolution in COVID-19 Patients

10.21203/rs.3.rs-443459/v1 ◽

2021 ◽

Author(s):

Samuele Ceruti ◽

Marco Roncador ◽

Andrea Saporito ◽

Maira Biggiogero ◽

Andrea Glotta ◽

...

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Mortality Rate ◽

Length Of Stay ◽

Positive End Expiratory Pressure ◽

Icu Mortality ◽

Icu Length Of Stay ◽

Therapeutic Anticoagulation ◽

D Dimer

Abstract Background Critically ill COVID-19 patients are burdened by high mortality. Evaluation to improve patients’ management was performed using strict patient criteria for Intensive Care Unit (ICU) admission, a low- positive end-expiratory pressure (PEEP) setting and standard thromboembolism treatment. Objectives of this study was to report the effects of this strategy on P/F-ratio evolution during mechanical ventilation (MV), ICU length of stay (LOS) and MV length.Methods A retrospective analysis was conducted on all consecutive patients with acute respiratory distress due to COVID-19 pneumonia admitted into ICU from March 2nd to January 15th, 2021. Patients were treated with a low-PEEP strategy (PEEP 10 cmH2O if BMI < 30 Kg m-2, PEEP 12 cmH2O if BMI 30-50 Kg m-2, PEEP 15 cmH2O if BMI > 50 Kg m-2) and therapeutic anticoagulation in case of thrombosis or D-dimer greater than 1’500 ng ml-1.Results 79 patients were on invasive MV. Average applied PEEP was 11 ± 2.9 cmH2O for BMI < 30 Kg m-2, 16 ± 3.18 cmH2O for BMI > 30 Kg m-2. After low-PEEP application, patients’ P/F ratio presented daily improvement from admission during next 72 hours (p<0.001; CI 99%) that resulted statistically significant for each single day after oro-tracheal intubation (OTI). Median ICU length of stay (LOS) was 15 days (10–28); median duration of MV was 12 days (8–26). The ICU mortality rate was 31.6%.Conclusions A combination of low-PEEP treatment resulted in P/F persistent daily ratio improvement during first 72 hours after OTI. A low-PEEP strategy could be beneficial in hemodynamic than respiratory terms.

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Impact of the Injectable Opioid Drug Shortage on Analgesia and Sedation Management in the Medical Intensive Care Unit: A Retrospective Cohort Study

Hospital Pharmacy ◽

10.1177/0018578721999805 ◽

2021 ◽

pp. 001857872199980

Author(s):

Kayla John ◽

Kari Cape ◽

Lauren Goodman ◽

Jessica Elefritz

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Cohort Study ◽

Intensive Care ◽

Length Of Stay ◽

Retrospective Cohort ◽

Medical Intensive Care Unit ◽

Drug Shortage ◽

Icu Length Of Stay ◽

Medical Intensive Care

Objectives: The purpose of this study was to assess the impact of the injectable opioid drug shortage on analgesia and sedation management in the medical intensive care unit (MICU). Methods: A single-center, retrospective cohort study was conducted of mechanically ventilated patients during the injectable opioid shortage. Outcomes were compared between a cohort of patients during the intravenous (IV) opioid shortage (01/01/18-03/31/18) and a control cohort (01/01/17-03/31/17). Total IV opioids and alternative sedative administration were assessed. Richmond Agitation Sedation Score (RASS) and Clinical Pain Observation Score (CPOT) assessments were also evaluated. The primary outcome was percentage of RASS within goal. Secondary outcomes included duration of mechanical ventilation, hospital/ICU length of stay, and mortality. Results: One hundred patients were included (50 patients per cohort). In the shortage cohort, 23.2% fewer IV opioids were used (40 501.8 vs 52 713.8 oral morphine equivalents [OME]). No statistical differences were found in percentage of patients within goal RASS between the shortage and control (median 63.7% vs 74.8%; P = .094) or CPOT (median 49.7% vs 47.7%; P = .575). More patients received enteral opioids and propofol on day 1 in the shortage cohort when compared to the control (22% vs 4%; P = .007 and 76% vs 56%; P = .035) but there were no differences in benzodiazepine, dexmedetomidine, or antipsychotic use. No differences in mechanical ventilation, hospital/ICU length of stay, or mortality were found. Conclusions: Use of less IV opioids during the injectable opioid shortage did not affect achievement of goal RASS and CPOT scores or increase prescribing of sedative medications such as benzodiazepines in the MICU.

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Healthcare trajectories before and after critical illness: population-based insight on diverse patients clusters

Annals of Intensive Care ◽

10.1186/s13613-019-0599-3 ◽

2019 ◽

Vol 9 (1) ◽

Cited By ~ 3

Author(s):

Youenn Jouan ◽

Leslie Grammatico-Guillon ◽

Noémie Teixera ◽

Claire Hassen-Khodja ◽

Christophe Gaborit ◽

...

Keyword(s):

Septic Shock ◽

Mechanical Ventilation ◽

Intensive Care ◽

Critical Illness ◽

Length Of Stay ◽

Population Based ◽

Hospital Length Of Stay ◽

Healthcare Use ◽

Icu Admission ◽

Icu Discharge

Abstract Background The post intensive care syndrome (PICS) gathers various disabilities, associated with a substantial healthcare use. However, patients’ comorbidities and active medical conditions prior to intensive care unit (ICU) admission may partly drive healthcare use after ICU discharge. To better understand retative contribution of critical illness and PICS—compared to pre-existing comorbidities—as potential determinant of post-critical illness healthcare use, we conducted a population-based evaluation of patients’ healthcare use trajectories. Results Using discharge databases in a 2.5-million-people region in France, we retrieved, over 3 years, all adult patients admitted in ICU for septic shock or acute respiratory distress syndrome (ARDS), intubated at least 5 days and discharged alive from hospital: 882 patients were included. Median duration of mechanical ventilation was 11 days (interquartile ranges [IQR] 8;20), mean SAPS2 was 49, and median hospital length of stay was 42 days (IQR 29;64). Healthcare use (days spent in healthcare facilities) was analyzed 2 years before and 2 years after ICU admission. Prior to ICU admission, we observed, at the scale of the whole study population, a progressive increase in healthcare use. Healthcare trajectories were then explored at individual level, and patients were assembled according to their individual pre-ICU healthcare use trajectory by clusterization with the K-Means method. Interestingly, this revealed diverse trajectories, identifying patients with elevated and increasing healthcare use (n = 126), and two main groups with low (n = 476) or no (n = 251) pre-ICU healthcare use. In ICU, however, SAPS2, duration of mechanical ventilation and length of stay were not different across the groups. Analysis of post-ICU healthcare trajectories for each group revealed that patients with low or no pre-ICU healthcare (which represented 83% of the population) switched to a persistent and elevated healthcare use during the 2 years post-ICU. Conclusion For 83% of ARDS/septic shock survivors, critical illness appears to have a pivotal role in healthcare trajectories, with a switch from a low and stable healthcare use prior to ICU to a sustained higher healthcare recourse 2 years after ICU discharge. This underpins the hypothesis of long-term critical illness and PICS-related quantifiable consequences in healthcare use, measurable at a population level.

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Global Muscle Strength But Not Grip Strength Predicts Mortality and Length of Stay in a General Population in a Surgical Intensive Care Unit

Physical Therapy ◽

10.2522/ptj.20110403 ◽

2012 ◽

Vol 92 (12) ◽

pp. 1546-1555 ◽

Cited By ~ 36

Author(s):

Jeanette J. Lee ◽

Karen Waak ◽

Martina Grosse-Sundrup ◽

Feifei Xue ◽

Jarone Lee ◽

...

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Intensive Care ◽

Length Of Stay ◽

Hospital Mortality ◽

Grip Strength ◽

Muscle Weakness ◽

Manual Muscle Testing ◽

Surgical Intensive Care Unit ◽

Muscle Testing

Background Paresis acquired in the intensive care unit (ICU) is common in patients who are critically ill and independently predicts mortality and morbidity. Manual muscle testing (MMT) and handgrip dynamometry assessments have been used to evaluate muscle weakness in patients in a medical ICU, but similar data for patients in a surgical ICU (SICU) are limited. Objective The purpose of this study was to evaluate the predictive value of strength measured by MMT and handgrip dynamometry at ICU admission for in-hospital mortality, SICU length of stay (LOS), hospital LOS, and duration of mechanical ventilation. Design This investigation was a prospective, observational study. Methods One hundred ten patients were screened for eligibility for testing in the SICU of a large, academic medical center. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, diagnoses, and laboratory data were collected. Measurements were obtained by MMT quantified with the sum (total) score on the Medical Research Council Scale and by handgrip dynamometry. Outcome data, including in-hospital mortality, SICU LOS, hospital LOS, and duration of mechanical ventilation, were collected for all participants. Results One hundred seven participants were eligible for testing; 89% were tested successfully at a median of 3 days (25th–75th percentiles=3–6 days) after admission. Sedation was the most frequent barrier to testing (70.6%). Manual muscle testing was identified as an independent predictor of mortality, SICU LOS, hospital LOS, and duration of mechanical ventilation. Grip strength was not independently associated with these outcomes. Limitations This study did not address whether muscle weakness translates to functional outcome impairment. Conclusions In contrast to handgrip strength, MMT reliably predicted in-hospital mortality, duration of mechanical ventilation, SICU LOS, and hospital LOS.

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Association between early mobilization or rehabilitation and intensive care unit acquired weakness: A systematic review and meta-analysis of randomized controlled trials.

10.21203/rs.3.rs-125436/v1 ◽

2020 ◽

Author(s):

Minghang Li ◽

Mingyue Ding ◽

Huanzhang Shao ◽

Bingyu Qin ◽

Xingwei Wang ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Meta Analysis ◽

Early Mobilization ◽

Standard Of Care ◽

Cochrane Library ◽

Care Group ◽

China National Knowledge Infrastructure ◽

Number Of Patients ◽

Icu Discharge

Abstract Background The prognosis of intensive care unit acquired weakness (ICUAW) is poor and the treatment effect is not ideal. At present, some effective and safe early prevention means are urgently needed to reduce its incidence.This study evaluated the effectiveness and safety of early activities or rehabilitation in the prevention of ICUAW. Methods We searched for articles in five electronic databases, including PubMed, EMBASE, the Cochrane Library, the China National Knowledge Infrastructure (CNKI) and Wanfang Med Online. All publications until June, 2020 were searched. We have selected trials investigating early mobilization or rehabilitation as compared to standard of care in critically ill adults.The extracted data included adverse events, the number of patients with ICUAW, the length of stay in the ICU (ICU-LOS) the length of mechanical ventilation (MV) etc. Results The final results showed that compared with the usual care group, early mobilization or rehabilitation reduced the prevalence of ICUAW (RR, 0.73; [0.61, 0.87]; I2 = 44%; P = 0.0006), ICU-LOS (MD, − 1.47;[2.83, 0.10]; I2 = 56%; P = 0.04), length of MV (MD, − 1.96; [2.41, 1.51]; I2 = 0%; P = 0.00001), but the mortality (RR, 0.90; [0.62, 1.32]; I2 = 3%; P = 0.60) at ICU discharge was not associated. The subgroup analysis of ICUAW prevalence and ICU-LOS based on the intervention methods showed that early combined rehabilitation could reduce the prevalence of ICUAW (RR, 0.56; [0.43, 0.74]; I2 = 34%; P = 0.0001) and shorten the ICU-LOS (MD, − 2.21; [3.28, 0.97]; I2 = 23%; P = 0.0003). EGDM was not associated with a decrease in ICUAW prevalence (RR, 0.85; [0.65, 1.09]; I2 = 26%; P = 0.20), but it reduced the ICU-LOS (MD, − 2.27; [3.86, 0.68]; I2 = 0%; P = 0.005).Early in-bed cycling was not associated with reduced ICUAW prevalence(RR, 1.25; [0.73, 2.13]; I2 = 0%; P = 0.41) and ICU-LOS(MD, 2.27; [0.27, 4.80]; I2 = 0%; P = 0.08) . Conclusions Early mobilization or rehabilitation was associated with a shorter length of MV and ICU-LOS, but not mortality. Of course, not all early activities or forms of rehabilitation are effective. The early combined rehabilitation model is effective for the prevention of ICUAW. However, EGDM and early in-bed cycling were not effective in preventing ICUAW.

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Residual Neuromuscular Blockade in Critical Care

Critical Care Nurse ◽

10.4037/ccn2012107 ◽

2012 ◽

Vol 32 (3) ◽

pp. e1-e10 ◽

Cited By ~ 4

Author(s):

Jason Wilson ◽

Angela S. Collins ◽

Brea O. Rowan

Keyword(s):

Intensive Care Unit ◽

Mechanical Ventilation ◽

Critical Care ◽

Intensive Care ◽

Neuromuscular Blockade ◽

Upper Airway ◽

Surgical Interventions ◽

Residual Neuromuscular Blockade ◽

Factors Affecting ◽

Anesthesia Time

Neuromuscular blockade is a pharmacological adjunct for anesthesia and for surgical interventions. Neuromuscular blockers can facilitate ease of instrumentation and reduce complications associated with intubation. An undesirable sequela of these agents is residual neuromuscular blockade. Residual neuromuscular blockade is linked to aspiration, diminished response to hypoxia, and obstruction of the upper airway that may occur soon after extubation. If an operation is particularly complex or requires a long anesthesia time, residual neuromuscular blockade can contribute to longer stays in the intensive care unit and more hours of mechanical ventilation. Given the risks of this medication class, it is essential to have an understanding of the mechanism of action of, assessment of, and factors affecting blockade and to be able to identify factors that affect pharmacokinetics.

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