Neurogenic vs. Myogenic Origin of Acquired Muscle Paralysis in Intensive Care Unit (ICU) Patients: Evaluation of Different Diagnostic Methods

Introduction. The acquired muscle paralysis associated with modern critical care can be of neurogenic or myogenic origin, yet the distinction between these origins is hampered by the precision of current diagnostic methods. This has resulted in the pooling of all acquired muscle paralyses, independent of their origin, into the term Intensive Care Unit Acquired Muscle Weakness (ICUAW). This is unfortunate since the acquired neuropathy (critical illness polyneuropathy, CIP) has a slower recovery than the myopathy (critical illness myopathy, CIM); therapies need to target underlying mechanisms and every patient deserves as accurate a diagnosis as possible. This study aims at evaluating different diagnostic methods in the diagnosis of CIP and CIM in critically ill, immobilized and mechanically ventilated intensive care unit (ICU) patients. Methods. ICU patients with acquired quadriplegia in response to critical care were included in the study. A total of 142 patients were examined with routine electrophysiological methods, together with biochemical analyses of myosin:actin (M:A) ratios of muscle biopsies. In addition, comparisons of evoked electromyographic (EMG) responses in direct vs. indirect muscle stimulation and histopathological analyses of muscle biopsies were performed in a subset of the patients. Results. ICU patients with quadriplegia were stratified into five groups based on the hallmark of CIM, i.e., preferential myosin loss (myosin:actin ratio, M:A) and classified as severe (M:A < 0.5; n = 12), moderate (0.5 ≤ M:A < 1; n = 40), mildly moderate (1 ≤ M:A < 1.5; n = 49), mild (1.5 ≤ M:A < 1.7; n = 24) and normal (1.7 ≤ M:A; n = 19). Identical M:A ratios were obtained in the small (4–15 mg) muscle samples, using a disposable semiautomatic microbiopsy needle instrument, and the larger (>80 mg) samples, obtained with a conchotome instrument. Compound muscle action potential (CMAP) duration was increased and amplitude decreased in patients with preferential myosin loss, but deviations from this relationship were observed in numerous patients, resulting in only weak correlations between CMAP properties and M:A. Advanced electrophysiological methods measuring refractoriness and comparing CMAP amplitude after indirect nerve vs. direct muscle stimulation are time consuming and did not increase precision compared with conventional electrophysiological measurements in the diagnosis of CIM. Low CMAP amplitude upon indirect vs. direct stimulation strongly suggest a neurogenic lesion, i.e., CIP, but this was rarely observed among the patients in this study. Histopathological diagnosis of CIM/CIP based on enzyme histochemical mATPase stainings were hampered by poor quantitative precision of myosin loss and the impact of pathological findings unrelated to acute quadriplegia. Conclusion. Conventional electrophysiological methods are valuable in identifying the peripheral origin of quadriplegia in ICU patients, but do not reliably separate between neurogenic vs. myogenic origins of paralysis. The hallmark of CIM, preferential myosin loss, can be reliably evaluated in the small samples obtained with the microbiopsy instrument. The major advantage of this method is that it is less invasive than conventional muscle biopsies, reducing the risk of bleeding in ICU patients, who are frequently receiving anticoagulant treatment, and it can be repeated multiple times during follow up for monitoring purposes.

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Quality improvement of delirium status communication and documentation for intensive care unit patients during daily multidisciplinary rounds

BMJ Open Quality ◽

10.1136/bmjoq-2017-000239 ◽

2018 ◽

Vol 7 (2) ◽

pp. e000239 ◽

Cited By ~ 2

Author(s):

Krishna Aparanji ◽

Shreedhar Kulkarni ◽

Megan Metzke ◽

Yvonne Schmudde ◽

Peter White ◽

...

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Tertiary Care ◽

Care Hospital ◽

Icu Patients ◽

Quality Metric ◽

Risk Of Mortality ◽

Simulation Based ◽

Multidisciplinary Rounds

Delirium is a key quality metric identified by The Society of Critical Care Medicine for intensive care unit (ICU) patients. If not recognised early, delirium can lead to increased length of stay, hospital and societal costs, ventilator days and risk of mortality. Clinical practice guidelines recommend ICU patients be assessed for delirium at least once per shift. An initial audit at our urban tertiary care hospital in Illinois, USA determined that delirium assessments were only being performed 31% of the time. Nurses completed simulation based education and were trained using delirium screening videos. After the educational sessions, delirium documentation increased from 40% (12/30) to 69% (41/59) (two-proportion test, p<0.01) for dayshift nurses and from 27% (8/30) to 61% (36/59) (two-proportion test, p<0.01) during the nightshift. To further increase the frequency of delirium assessments, the delirium screening tool was standardised and a critical care progress note was implemented that included a section on delirium status, management strategy and discussion on rounds. After the documentation changes were implemented, delirium screening during dayshift increased to 93% (75/81) (two-proportion test, p<0.01). Prior to this project, physicians were not required to document delirium screening. After the standardised critical care note was implemented, documentation by physicians was 95% (106/111). Standardising delirium documentation, communication of delirium status on rounds, in addition to education, improved delirium screening compliance for ICU patients.

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The effect of two concentrations of heparin on arterial catheter patency

Critical Care Nurse ◽

10.4037/ccn1990.10.5.47 ◽

1990 ◽

Vol 10 (5) ◽

pp. 47-57 ◽

Cited By ~ 10

Author(s):

CS Bolgiano ◽

PT Subramaniam ◽

JM Montanari ◽

L Minick

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Hemodynamic Monitoring ◽

Arterial Catheter ◽

Arterial Line ◽

Routine Procedure ◽

Icu Patients ◽

Catheter Patency

The use of invasive lines with heparinized fluid for hemodynamic monitoring is a routine procedure in critical care areas. The main objective of this study was to compare the duration of patency of indwelling arterial catheter lines and patient coagulation values when the recommended dilution of 1.0 U heparin/mL was used versus the use of only 0.25 U heparin/mL. One hundred four intensive care unit (ICU) patients were studied. There were no significant differences between the two groups in patency or coagulation values. The results of the study demonstrated that 0.25 U heparin/mL was sufficient to maintain arterial line patency for patients with lines in place for up to 3 days.

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Telemedicine coverage for post-operative ICU patients

Journal of Telemedicine and Telecare ◽

10.1177/1357633x16631846 ◽

2016 ◽

Vol 23 (2) ◽

pp. 360-364 ◽

Cited By ~ 10

Author(s):

Tara Ann Collins ◽

Matthew P Robertson ◽

Corinna P Sicoutris ◽

Michael A Pisa ◽

Daniel N Holena ◽

...

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Care Service ◽

Surgical Intensive Care Unit ◽

Surgical Intensive Care ◽

Surge Capacity ◽

Icu Patients ◽

Critical Care Service ◽

Surgical Critical Care

Introduction There is an increased demand for intensive care unit (ICU) beds. We sought to determine if we could create a safe surge capacity model to increase ICU capacity by treating ICU patients in the post-anaesthesia care unit (PACU) utilizing a collaborative model between an ICU service and a telemedicine service during peak ICU bed demand. Methods We evaluated patients managed by the surgical critical care service in the surgical intensive care unit (SICU) compared to patients managed in the virtual intensive care unit (VICU) located within the PACU. A retrospective review of all patients seen by the surgical critical care service from January 1st 2008 to July 31st 2011 was conducted at an urban, academic, tertiary centre and level 1 trauma centre. Results Compared to the SICU group ( n = 6652), patients in the VICU group ( n = 1037) were slightly older (median age 60 (IQR 47–69) versus 58 (IQR 44–70) years, p = 0.002) and had lower acute physiology and chronic health evaluation (APACHE) II scores (median 10 (IQR 7–14) versus 15 (IQR 11–21), p < 0.001). The average amount of time patients spent in the VICU was 13.7 + /–9.6 hours. In the VICU group, 750 (72%) of patients were able to be transferred directly to the floor; 287 (28%) required subsequent admission to the surgical intensive care unit. All patients in the VICU group were alive upon transfer out of the PACU while mortality in the surgical intensive unit cohort was 5.5%. Discussion A collaborative care model between a surgical critical care service and a telemedicine ICU service may safely provide surge capacity during peak periods of ICU bed demand. The specific patient populations for which this approach is most appropriate merits further investigation.

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Long-Term Cognitive Impairment After Critical Illness

50 Studies Every Anesthesiologist Should Know ◽

10.1093/med/9780190237691.003.0017 ◽

2018 ◽

pp. 86-90

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Cognitive Impairment ◽

Critical Illness ◽

Cognitive Outcomes ◽

Adult Patients ◽

Illness Experience ◽

Icu Patients ◽

Global Cognition

This case focuses on long-term cognitive impairment after critical illness by asking the question: What is the prevalence of long-term cognitive impairment after critical illness, and does the duration of delirium and use of sedative or analgesic medications affect cognitive outcomes? This study demonstrated that 74% of adult patients with critical illness experience delirium during their hospital course. Furthermore, patients in the intensive care unit (ICU) setting commonly experience global cognition and executive function deficits at 3 and 12 months following hospitalization. These findings highlight the importance of careful delirium surveillance in ICU patients.

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Intensive Care Nurses’ Views and Practices for Eye Care: An International Comparison

Clinical Nursing Research ◽

10.1177/1054773816631471 ◽

2016 ◽

Vol 26 (4) ◽

pp. 504-524 ◽

Cited By ~ 6

Author(s):

Elem Kocaçal Güler ◽

İsmet Eşer ◽

Imad Hussein Deeb Fashafsheh

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Normal Saline ◽

Descriptive Study ◽

Sterile Water ◽

Eye Care ◽

Icu Patients ◽

Intensive Care Nurses ◽

Critical Patients

Eye care is an important area of critical care. However, lack of eye care studies is a common issue across the globe. The aim of this study is to determine the views and practices of intensive care unit (ICU) nurses on eye care in Turkey and Palestine. This descriptive study was conducted using a self-administrated questionnaire. The data were collected from 111 nurses in nine kinds of ICUs in two education hospital. Normal saline (75.9%) was the most commonly reported solution for eye hygiene among the Palestinian nurses, and gauze soaked in normal saline or sterile water (64.3%) were the most frequently used supplies by the Turkish nurses. Although both Palestinian and Turkish ICU nurses took some precautions to prevent eye complications in critical patients, there were some gaps and insufficiencies in the eye care of ICU patients. There is a need for continuing training in this area.

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Validation of the Critical-Care Pain Observation Tool-Neuro in brain-injured adults in the intensive care unit: a prospective cohort study

Critical Care ◽

10.1186/s13054-021-03561-1 ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Céline Gélinas ◽

Mélanie Bérubé ◽

Kathleen A. Puntillo ◽

Madalina Boitor ◽

Melissa Richard-Lalonde ◽

...

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Cohort Study ◽

Intensive Care ◽

Pain Intensity ◽

Prospective Cohort Study ◽

Prospective Cohort ◽

Data Set ◽

Icu Patients ◽

Brain Injured

Abstract Background Pain assessment in brain-injured patients in the intensive care unit (ICU) is challenging and existing scales may not be representative of behavioral reactions expressed by this specific group. This study aimed to validate the French-Canadian and English revised versions of the Critical-Care Pain Observation Tool (CPOT-Neuro) for brain-injured ICU patients. Methods A prospective cohort study was conducted in three Canadian and one American sites. Patients with a traumatic or a non-traumatic brain injury were assessed with the CPOT-Neuro by trained raters (i.e., research staff and ICU nurses) before, during, and after nociceptive procedures (i.e., turning and other) and non-nociceptive procedures (i.e., non-invasive blood pressure, soft touch). Patients who were conscious and delirium-free were asked to provide their self-report of pain intensity (0–10). A first data set was completed for all participants (n = 226), and a second data set (n = 87) was obtained when a change in the level of consciousness (LOC) was observed after study enrollment. Three LOC groups were included: (a) unconscious (Glasgow Coma Scale or GCS 4–8); (b) altered LOC (GCS 9–12); and (c) conscious (GCS 13–15). Results Higher CPOT-Neuro scores were found during nociceptive procedures compared to rest and non-nociceptive procedures in both data sets (p < 0.001). CPOT-Neuro scores were not different across LOC groups. Moderate correlations between CPOT-Neuro and self-reported pain intensity scores were found at rest and during nociceptive procedures (Spearman rho > 0.40 and > 0.60, respectively). CPOT-Neuro cut-off scores ≥ 2 and ≥ 3 were found to adequately classify mild to severe self-reported pain ≥ 1 and moderate to severe self-reported pain ≥ 5, respectively. Interrater reliability of raters’ CPOT-Neuro scores was supported with intraclass correlation coefficients > 0.69. Conclusions The CPOT-Neuro was found to be valid in this multi-site sample of brain-injured ICU patients at various LOC. Implementation studies are necessary to evaluate the tool’s performance in clinical practice.

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Animal-Assisted Interventions in Intensive Care Delirium: A Literature Review

AACN Advanced Critical Care ◽

10.4037/aacnacc2021708 ◽

2021 ◽

Vol 32 (4) ◽

pp. 391-397

Author(s):

Jahanzeb Malik

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Cognitive Function ◽

Critical Illness ◽

The Body ◽

High Incidence ◽

The Mind ◽

Animal Assisted Intervention

Critical illness has lasting consequences on the mind and the body. Acute sequelae include a decline in cognitive function known as delirium. Increased interest in improving outcomes for intensive care unit survivors without a high incidence of delirium has initiated a focus on an array of nonpharmacologic interventions in many countries. One such intervention is animalassisted intervention. As the role of animals in human healing is being recognized by clinicians, need is increasing for formal and professionally directed therapies. This review ascertains the effect of interaction with animals on critically ill patients. Emerging evidence indicates that animal-assisted intervention improves the efficacy of critical care regarding primary symptoms and secondary factors of delirium.

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Infectious Diseases Complicating Critical Care

Mayo Clinic Critical and Neurocritical Care Board Review ◽

10.1093/med/9780190862923.003.0058 ◽

2019 ◽

pp. 369-374

Author(s):

David A. Sotello Aviles ◽

Walter C. Hellinger

Keyword(s):

Patient Outcome ◽

Intensive Care Unit ◽

Staphylococcus Aureus ◽

Antibiotic Resistance ◽

Critical Care ◽

Intensive Care ◽

Critical Illness ◽

Mortality Rate ◽

Common Complication ◽

Improve Patient

Infection is a common complication in the intensive care unit (ICU). Furthermore, infection more than doubles the mortality rate in the ICU. Antibiotic resistance in Staphylococcus aureus, Enterococcus, Enterobacteriaceae, and fungal infection is among the most challenging issues in the ICU. In addition, critical illness affects antibiotic pharmacokinetics. Thus, implementation of strategies to prevent infection is of utmost importance to improve patient outcome.

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A atuação do terapeuta ocupacional em Unidade de Terapia Intensiva: uma revisão sistemática

Cadernos Brasileiros de Terapia Ocupacional ◽

10.1590/2526-8910.ctoar2118 ◽

2021 ◽

Vol 29 ◽

Author(s):

Estéfanny da Silva Bittencourt ◽

Paula Silva Moreira ◽

Glenda Miranda da Paixão ◽

Marcelo Marques Cardoso

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Critical Illness ◽

Occupational Therapy ◽

Terapia Intensiva

Resumo Introdução A participação do terapeuta ocupacional (TO) em Unidades de Terapia Intensiva (UTI) ainda é discreta no Brasil, talvez, por isso, haja pouca discussão das intervenções e inserção do profissional nessa área. Objetivo Sintetizar as atuações do TO para restabelecimento da função em pacientes adultos internados na UTI mais frequentemente descritas na literatura especializada. Método Revisão Sistemática baseada na recomendação PRISMA. A busca dos estudos foi realizada nas plataformas Cochrane, PubMed, OTSeek e PEDro, utilizando os termos de busca “Occupational Therapy”, no título ou resumo, (AND) “Intensive Care Unit” (OR) “Critical Illness” (OR) “Critical Care”, em outras partes do texto. Foram incluídos textos em língua inglesa e publicados nos últimos 20 anos. Excluiu-se textos que abordavam UTI pediátrica/neonatal, doenças psiquiátricas e artigos de revisão. Dois pesquisadores independentes selecionaram os artigos e a concordância foi submetida à análise Kappa. O nível de evidência e a qualidade metodológica dos estudos incluídos foram avaliados pela Escala PEDro e pela Ferramenta de Colaboração Cochrane, respectivamente. Resultados As principais intervenções foram relativas ao treino de Atividades de Vida Diária (AVDs) e tarefas relacionadas às Atividades Instrumentais de Vida Diária (AIVDs). Essas atribuições privativas da profissão ocorreram isoladamente ou com fisioterapeutas. As sessões, excluídos os critérios de contraindicação, aconteceram precocemente (24-48h). Conclusão Os achados evidenciam intervenções de mobilização precoce, seguidas por práticas de treino de AVDs/ AIVDs. Ademais, é notado que a atuação do terapeuta ocupacional na UTI está em elaboração. Estudos sobre outros efeitos da internação prolongada na UTI devem ser conduzidos. Registro PROSPERO: CRD42020214615.

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INVASIVE ASPERGILLOSIS IN INTENSIVE CARE UNIT PATIENTS IN IRAN

Acta Medica (Hradec Kralove Czech Republic) ◽

10.14712/18059694.2014.24 ◽

2013 ◽

Vol 56 (2) ◽

pp. 52-56 ◽

Cited By ~ 5

Author(s):

Mohammad T. Hedayati ◽

Sadegh Khodavaisy ◽

Masoud Alialy ◽

Saeed Mahdavi Omran ◽

Mohammad R. Habibi

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Bronchoalveolar Lavage ◽

Invasive Aspergillosis ◽

Microscopic Examination ◽

Diagnostic Methods ◽

Fungal Culture ◽

Icu Patients ◽

Gm Detection ◽

Predisposing Conditions

We assessed the intensive care unit (ICU) patients for Invasive aspergillosis (IA) with culture and non-culture based diagnostic methods from Iran. Thirty-six ICU patients with underlying predisposing conditions for IA were enrolled in the study. Sixty eight Bronchoalveolar lavage (BAL) samples were collected by bronchoscope twice a weekly. BAL samples were analyzed by microscopic examination, fungal culture and galactomannan (GM) detection. The Platelia Aspergillus GM EIA was used to quantify GM indices. Samples with a BAL GM index ≥1 were considered as positive for GM. Patients were classified as having probable or possible IA. Out of 36 suspected patients to IA, 36.1% of cases showed IA which were categorized as: 4 cases of possible IA and 9 of probable IA. 76.2% of BAL samples were positive for GM. From 13 patients with IA, 11 (84.6%) had at least one positive BAL GM index. Of these patients, 9 (81.8%) showed probable IA. The main underlying predisposing conditions were neutropenia (53.8%) and COPD (30.8%). Our study has indicated that COPD must be considered as one of the main predisposing condition for occurrence of aspergillosis in ICU patients. Our data have also revealed that GM detection in BAL samples play a significant role to IA diagnosis.

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