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Introduction: Implementing the ABCDEF bundle has demonstrated improved outcomes in patients with critical illness. This study aims to describe the daily compliance of the ABCDEF bundle in a Chilean intensive care unit. Methods: Retrospective observational study of electronic clinical records of nursing, physiotherapy, and medical professionals who cared for patients over 18 years of age, admitted to an intensive care unit for at least 24 hours, with or without mechanical ventilation. Daily bundle compliance was determined by considering the daily records for each element: Assess pain (element A), both spontaneous awakening trials (element B1) and spontaneous breathing trials (element B2), choice of sedation (element C), delirium assessment (element D), early mobilization (element E), and family engagement (element F). Results: 4165 registered bundle elements were obtained from nursing (47%), physiotherapy (44%), and physicians (7%), including 1134 patient/days (from 133 patients). Elements E and C showed 67 and 40% compliance, while D, A, and B2 showed 24, 14 and 11%, respectively. For B1 and F, 0% compliance was achieved. Compliance was higher in patients without mechanical ventilation for A and E, while it was similar for D. Conclusions: Early mobilization had the highest compliance, while spontaneous awakening trials and family engagement had absolute non-compliance. Future studies should explore the reasons for the different degrees of compliance per bundle element in clinical practice.
Introducción: La implementación del ABCDEF ha demostrado mejores resultados en los pacientes críticos. El objetivo de este trabajo es identificar el cumplimiento del registro diario del ABCDEF en una unidad de cuidados intensivos chilena. Métodos: Estudio observacional retrospectivo de los registros clínicos electrónicos de profesionales de enfermería, kinesiología y medicina que trataron a pacientes mayores de 18 años, hospitalizados en una unidad de cuidados intensivos durante al menos 24 horas, con o sin requerimiento de ventilación mecánica. Se determinó el cumplimiento diario del considerando la presencia del registro en la ficha clínica de cada elemento: evaluación del dolor (elemento A), prueba de interrupción de la sedación (elemento B1) y ventilación espontánea (elemento B2), elección de la sedación (elemento C), evaluación del (elemento D), movilización temprana (elemento E) y empoderamiento de la familia (elemento F). Resultados: Se obtuvieron 4165 elementos del registrados provenientes de enfermería (47%), kinesiología (44%) y medicina (7%), incluyendo 1134 días/paciente (133 pacientes). Los elementos E y C mostraron un cumplimiento del 67 y 40%, mientras que D, A, y B2 mostraron 24, 14 y 11%, respectivamente. Para B1 y F se obtuvo 0% de cumplimiento. El cumplimiento fue mayor en los pacientes sin ventilación mecánica para A y E, mientras que para D fue similar. Conclusiones: La movilización temprana fue el elemento con mayor cumplimiento, mientras que las pruebas de interrupción de sedación y el empoderamiento de la familia tuvieron incumplimiento absoluto. Futuros estudios deberían explorar las razones que expliquen los diferentes grados de cumplimiento por elemento del en la práctica clínica.
Subject(s)
Critical Illness , Intensive Care Units , Respiration, Artificial , Humans , Retrospective Studies , Respiration, Artificial/methods , Respiration, Artificial/statistics & numerical data , Male , Middle Aged , Female , Aged , Chile , Early Ambulation , Guideline Adherence , Patient Care Bundles/methods , Critical Care/methods , Delirium , Adult , Physical Therapy ModalitiesABSTRACT
Introduction/Aims: Muscle ultrasound has high utility in clinical practice and research; however, the main challenges are the training and time required for manual analysis to achieve objective quantification of morphometry. This study aimed to develop and validate a software tool powered by artificial intelligence (AI) by measuring its consistency and predictability of expert manual analysis quantifying lower limb muscle ultrasound images across healthy, acute, and chronic illness subjects. Methods: Quadriceps complex (QC [rectus femoris and vastus intermedius]) and tibialis anterior (TA) muscle ultrasound images of healthy, intensive care unit, and/or lung cancer subjects were captured with portable devices. Automated analyses of muscle morphometry were performed using a custom-built deep-learning model (MyoVision-US), while manual analyses were performed by experts. Consistency between manual and automated analyses was determined using intraclass correlation coefficients (ICC), while predictability of MyoVision -US was calculated using adjusted linear regression (adj.R 2 ). Results: Manual analysis took approximately 24 hours to analyze all 180 images, while MyoVision - US took 247 seconds, saving roughly 99.8%. Consistency between the manual and automated analyses by ICC was good to excellent for all QC (ICC:0.85-0.99) and TA (ICC:0.93-0.99) measurements, even for critically ill (ICC:0.91-0.98) and lung cancer (ICC:0.85-0.99) images. The predictability of MyoVision-US was moderate to strong for QC (adj.R 2 :0.56-0.94) and TA parameters (adj.R 2 :0.81-0.97). Discussion: The application of AI automating lower limb muscle ultrasound analyses showed excellent consistency and strong predictability compared with human analysis. Future work needs to explore AI-powered models for the evaluation of other skeletal muscle groups.
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Introducción. Las tasas de retención en los estudios de seguimiento oscilan entre el 32 y 100%, demostrando el desafío que implica realizar estudios longitudinales de sobrevivientes de la unidad de cuidados intensivos (UCI). Objetivo. Identificar las estrategias implementadas y lecciones aprendidas en un estudio prospectivo multicéntrico de seguimiento de sobrevivientes de la UCI durante la pandemia. Métodos. Estudio post-hoc de las lecciones aprendidas mediante encuestas y entrevistas dirigidas a explorar la experiencia de los investigadores y coordinadores del estudio IMPACCT COVID-19, realizado en siete centros chilenos entre octubre 2020 y abril 2021 evaluando el síndrome post-cuidados intensivos de sobrevivientes hasta seis meses después. Resultados. Identificamos ocho lecciones: 1) selección de instrumentos de medición, 2) identificación de centros participantes, 3) aprobación del estudio, 4) financiamiento, 5) capacitación de evaluadores, 6) coordinación/aseguramiento de calidad, 7) reclutamiento y 8) seguimiento de pacientes. Incluso durante el primer año de pandemia, reclutamos 252 pacientes a una tasa de 1,4 pacientes/día con una retención del 48% a los 6 meses de seguimiento. El uso de redes académicas existentes y las estrategias de comunicación entre investigadores, coordinadores y evaluadores fueron aspectos positivos; mientras que la fidelización con evaluadores al egreso de la UCI y con pacientes durante el seguimiento son aspectos que deberían considerarse en futuros estudios. Conclusiones. Se evaluaron más de 250 pacientes en seis meses durante la pandemia, con tasas de retención post UCI acorde a la literatura. Futuros estudios debiesen optimizar los procesos de medición y de seguimiento para minimizar la pérdida de pacientes.
Background. Retention rates of follow-up studies range from 32 to 100%, demonstrating the challenge to conduct longitudinal studies of intensive care unit (ICU) survivors. Objective. To identify the strategies implemented and lessons learned in a multicenter prospective follow-up study of ICU survivors during pandemic times. Methods. Post-hoc study of lessons learned through surveys and interviews aimed at exploring the experience of the researchers and coordinators of the IMPACCT COVID-19 study. The original study was performed in seven Chilean sites between October 2020 and April 2021 evaluating the post-intensive care syndrome of survivors up to six-month follow-up. Results. We identified eight lessons: 1) selection of measurement instruments, 2) identification of participating sites, 3) Study approval, 4) funding, 5) evaluators training, 6) coordination/quality assurance, 7) recruitment, and 8) patient follow-up. Even during the first year of the pandemic, we recruited 252 patients at a rate of 1.4 patients/day with a retention rate of 48% at 6 months of follow-up. The use of existing academic networks and communication strategies between researchers, coordinators and evaluators were positive aspects; while evaluators fidelity at ICU discharge and patient engagement during follow-up are aspects should be considered. Conclusions. More than 250 patients were evaluated in six months during the pandemic, with post-ICU retention rates consistent with the literature. Future studies should optimize measurement and monitoring processes to minimize patient atrition.
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OBJECTIVE: The aim of this scoping review was to investigate the mobilization dose reporting in the randomized clinical trials (RCTs) of patients receiving mechanical ventilation in the intensive care unit. METHODS: In this scoping review, RCTs published from inception to December 2022 were searched in relevant electronic databases. Trials that involved adults receiving mechanical ventilation (>48 hours) and any early mobilization modality were analyzed. Two independent authors screened, selected, and extracted data. The mobilization doses of the intervention groups (IG) and the comparator groups (CG) were assessed as the proportion of reported items/total applicable from the main items of the Consensus on Exercise Reporting Template (CERT). RESULTS: Twenty-three RCTs comprising 2707 patients (1358 from IG and 1349 from CG) were included, involving studies on neuromuscular electrical stimulation (n = 7), progressive mobility (n = 6), leg cycling (n = 3), tilt table (n = 1), and multicomponent (n = 6) mobilization. The pooled reporting of CERT items was 68% (86% for IG and 50% for CG). The most reported CERT items were type of exercise (100%) and weekly frequency (100%) for IG, whereas the least reported were intensity (4%) and individualization (22%) for CG. Regardless of the group, individualization, progression, and intensity of mobilization were the least reported items. Eight IGs (35%) reported all CERT items, whereas no CGs reported all of them. CONCLUSIONS: Deficits in mobilization dose reporting of intensive care unit RCTs were identified, especially for exercise intensity in adults receiving mechanical ventilation. One-third of IG reported all exercise dosing items, whereas no CG reported all of them. Future studies should investigate the details of optimal dosage reporting, particularly for CG. IMPACT: The lack of dose reporting may partially explain the inconsistency in the meta-analysis results of early mobilization trials, thus limiting the interpretation for clinical practice in the intensive care unit.
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INTRODUCTION: The COVID-19 pandemic can be seen as a natural experiment to test how bed occupancy affects post-intensive care unit (ICU) patient's functional outcomes. To compare by bed occupancy the frequency of mental, physical, and cognitive impairments in patients admitted to ICU during the COVID-19 pandemic. METHODS: Prospective cohort of adults mechanically ventilated >48 hours in 19 ICUs from seven Chilean public and private hospitals. Ninety percent of nationwide beds occupied was the cut-off for low versus high bed occupancy. At ICU discharge, 3- and 6-month follow-up, we assessed disability using the World Health Organization Disability Assessment Schedule 2.0. Quality of life, mental, physical, and cognitive outcomes were also evaluated following the core outcome set for acute respiratory failure. RESULTS: We enrolled 252 participants, 103 (41%) during low and 149 (59%) during high bed occupancy. Patients treated during high occupancy were younger (P50 [P25-P75]: 55 [44-63] vs 61 [51-71]; p<0.001), more likely to be admitted due to COVID-19 (126 [85%] vs 65 [63%]; p<0.001), and have higher education qualification (94 [63%] vs 48 [47%]; p = 0.03). No differences were found in the frequency of at least one mental, physical or cognitive impairment by bed occupancy at ICU discharge (low vs high: 93% vs 91%; p = 0.6), 3-month (74% vs 63%; p = 0.2) and 6-month (57% vs 57%; p = 0.9) follow-up. CONCLUSIONS: There were no differences in post-ICU outcomes between high and low bed occupancy. Most patients (>90%) had at least one mental, physical or cognitive impairment at ICU discharge, which remained high at 6-month follow-up (57%). CLINICAL TRIAL REGISTRATION: NCT04979897 (clinicaltrials.gov).
Subject(s)
Bed Occupancy , COVID-19 , Adult , Humans , Prospective Studies , COVID-19/epidemiology , Pandemics , Quality of Life , Critical Care , Intensive Care UnitsABSTRACT
INTRODUCTION: Several systematic reviews (SRs) have been conducted to determine the effectiveness of early mobilisation in critically ill adults with heterogeneous methodology and results. Redundancy in conducting SRs, unclear justification when leading new SRs or updating, and discordant results of SRs on the same research question may generate research waste that makes it difficult for clinicians to keep up to date with the best available evidence. This meta-research aims to assess the redundancy, methodological and reporting quality, and potential reasons for discordance in the results reported by SRs conducted to determine the effectiveness of early mobilisation in critically ill adult patients. METHODS AND ANALYSIS: A meta-research of early mobilisation SRs in critically ill adult patients will be conducted. A search of MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Cochrane Library, Epistemonikos and other search resources will be conducted. Two independent reviewers will perform study selection, data extraction and quality appraisal. Discrepancies will be resolved by consensus or a third reviewer. The redundancy of SRs will be assessed by the degree of overlap of primary studies. In addition, the justification for conducting new SRs will be evaluated with the 'Evidence-Based Research' framework. The methodological quality of the SRs will be assessed with the A MeaSurement Tool to Assess systematic Reviews 2 tool, and the quality of the reports through compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. To assess the potential reasons for discordance in the results of the SRs considering divergence in results and their interpretation. ETHICS AND DISSEMINATION: As meta-research, this study does not involve the participation of people whose rights may be violated. However, this overview will be developed rigorously and systematically to achieve valid and reliable results. The findings of this meta-research study will be presented at conferences and published in a peer-reviewed journal related to rehabilitation, critical care or research methodology. TRIAL REGISTRATION NUMBER: osf.io/kxwq9.
Subject(s)
Critical Illness , Early Ambulation , Adult , Humans , Critical Illness/therapy , Critical Care , Research Design , Peer ReviewABSTRACT
INTRODUCTION: Acute kidney injury requiring renal replacement therapy (AKI-RRT) is common in the intensive care unit (ICU) and is associated with significant morbidity and mortality. Continuous RRT (CRRT) non-selectively removes large amounts of amino acids from plasma, lowering serum amino acid concentrations and potentially depleting total-body amino acid stores. Therefore, the morbidity and mortality associated with AKI-RRT may be partly mediated through accelerated skeletal muscle atrophy and resulting muscle weakness. However, the impact of AKI-RRT on skeletal muscle mass and function during and following critical illness remains unknown. We hypothesise that patients with AKI-RRT have higher degrees of acute muscle loss than patients without AKI-RRT and that AKI-RRT survivors are less likely to recover muscle mass and function when compared with other ICU survivors. METHODS AND ANALYSIS: This protocol describes a prospective, multicentre, observational trial assessing skeletal muscle size, quality and function in ICU patients with AKI-RRT. We will perform musculoskeletal ultrasound to longitudinally evaluate rectus femoris size and quality at baseline (within 48 hours of CRRT initiation), day 3, day 7 or at ICU discharge, at hospital discharge, and 1-3 months postdischarge. Additional skeletal muscle and physical function tests will be performed at hospital discharge and postdischarge follow-up. We will analyse the effect of AKI-RRT by comparing the findings in enrolled subjects to historical controls of critically ill patients without AKI-RRT using multivariable modelling. ETHICS AND DISSEMINATION: We anticipate our study will reveal that AKI-RRT is associated with greater degrees of muscle loss and dysfunction along with impaired postdischarge recovery of physical function. These findings could impact the in-hospital and postdischarge treatment plan for these patients to include focused attention on muscle strength and function. We intend to disseminate findings to participants, healthcare professionals, the public and other relevant groups via conference presentation and publication without any publication restrictions. TRIAL REGISTRATION NUMBER: NCT05287204.
Subject(s)
Acute Kidney Injury , Continuous Renal Replacement Therapy , Muscular Diseases , Humans , Acute Kidney Injury/etiology , Aftercare , Critical Illness/therapy , Intensive Care Units , Multicenter Studies as Topic , Observational Studies as Topic , Patient Discharge , Prospective Studies , Renal Replacement Therapy/methodsABSTRACT
INTRODUCTION: Adult and pediatric patients admitted to intensive care units (ICUs) requiring invasive ventilatory support, sedation, and muscle blockade may present neuromusculoskeletal deterioration. Different physical rehabilitation interventions have been studied to evaluate their effectiveness in improving critically ill patients' outcomes. Given that many published systematic reviews (SRs) aims to determine the effectiveness of different types of physical rehabilitation interventions, it is necessary to group them systematically and assess the methodological quality of SRs to help clinicians make better evidence-based decisions. This overview of SRs (OoSRs) aims to map the existing evidence and to determine the effectiveness of physical rehabilitation interventions to improve neuromusculoskeletal function and other clinical outcomes in adult and pediatric critically ill patients. METHODS: An OoSRs of randomized and non-randomized clinical trials involving critically ill adult and pediatric patients receiving physical rehabilitation intervention will be conducted. A sensitive search of MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), Cochrane Library, Epistemonikos, and other search resources will be conducted. Two independent reviewers will conduct study selection, data extraction, and methodological quality assessment. Discrepancies will be resolved by consensus or a third reviewer. The degree of overlap of studies will be calculated using the corrected covered area. The methodological quality of the SRs will be measured using the AMSTAR-2 tool. The GRADE framework will report the certainty of evidence by selecting the "best" SR for each physical rehabilitation intervention and outcome. DISCUSSION: The findings of this overview are expected to determine the effectiveness and safety of physical rehabilitation interventions to improve neuromusculoskeletal function in adult and pediatric critically ill patients based on a wide selection of the best available evidence and to determine the knowledge gaps in this topic by mapping and assessing the methodological quality of published SRs. REGISTRATION NUMBER: CRD42023389672.
Subject(s)
Critical Illness , Intensive Care Units , Adult , Child , Humans , Hospitalization , Systematic Reviews as TopicABSTRACT
Acute kidney injury (AKI) and intensive care unit-acquired weakness (ICU-AW) are 2 frequent complications of critical illness that, until recently, have been considered unrelated processes. The adverse impact of AKI on ICU mortality is clear, but its relationship with muscle weakness-a major source of ICU morbidity-has not been fully elucidated. Furthermore, improving ICU survival rates have refocused the field of intensive care toward improving long-term functional outcomes of ICU survivors. We begin our review with the epidemiology of AKI in the ICU and of ICU-AW, highlighting emerging data suggesting that AKI and AKI treated with kidney replacement therapy (AKI-KRT) may independently contribute to the development of ICU-AW. We then delve into human and animal data exploring the pathophysiologic mechanisms linking AKI and acute KRT to muscle wasting, including altered amino acid and protein metabolism, inflammatory signaling, and deleterious removal of micronutrients by KRT. We next discuss the currently available interventions that may mitigate the risk of ICU-AW in patients with AKI and AKI-KRT. We conclude that additional studies are needed to better characterize the epidemiologic and pathophysiologic relationship between AKI, AKI-KRT, and ICU-AW and to prospectively test interventions to improve the long-term functional status and quality of life of AKI survivors.
Subject(s)
Acute Kidney Injury , Quality of Life , Humans , Intensive Care Units , Critical Care , Renal Replacement Therapy/adverse effects , Acute Kidney Injury/therapy , Critical IllnessABSTRACT
BACKGROUND: Physical functioning evaluation in intensive care units (ICUs) identifies rehabilitation requirements and response to interventions. AIM: To identify the usage rate of physical functioning measurement instruments in ICUs during the COVID-19 pandemic in Chile. MATERIAL AND METHODS: Lead physiotherapists representing different national ICUs were invited to answer a National online survey at the onset (T1) and at the first year of COVID-19 pandemic (T2). The usage rate (defined as "always"/"almost always"/"almost never"/"never") of instruments assessing muscle strength, muscle mass, mobility, and physical performance was surveyed. Also, the reasons for selecting these instruments were requested. RESULTS: We received responses from 94 and 93 ICUs at T1 and T2, respectively, of 111 eligible ICUs (55% public). Compared with T2, the usage rate of instruments was lower at T1, and significant only for Medical Research Sum-Score (MRC-SS) (p = 0.04) and handgrip dynamometry (p = 0.05). Considering the answers "always", "almost always" and "almost never", between 89% and 91% of the ICUs reported the use of the MRC-SS; between 70% and 73% reported the use of the Functional Status Score for the Intensive Care Unit; between 5% and 35% of the ICUs reported the use of the rest of mobility scales; and between 44%-45% of ICUs reported that muscle ultrasound was "almost never" used. The main reasons reported for selecting instruments were quick use and clinimetric properties. CONCLUSIONS: The usage rate of muscle strength assessments was frequent, while the use of mobility and muscle mass instruments recommended by the literature was poorly reported, which was lower at the onset of the pandemic.
Subject(s)
Humans , Male , Female , Adult , Critical Care , Physical Therapists , Physical Functional Performance , COVID-19 , Chile/epidemiology , Cross-Sectional Studies , Surveys and Questionnaires , Muscle Strength , Pandemics , Intensive Care UnitsABSTRACT
Technological advances in mechanical ventilation have been essential to increasing the survival rate in intensive care units. Usually, patients needing mechanical ventilation use controlled ventilation to override the patients respiratory muscles and favor lung protection. Weaning from mechanical ventilation implies a transition towards spontaneous breathing, mainly using assisted mechanical ventilation. In this transition, the challenge for clinicians is to avoid under and over assistance and minimize excessive respiratory effort and iatrogenic diaphragmatic and lung damage. Esophageal balloon monitoring allows objective measurements of respiratory muscle activity in real time, but there are still limitations to its routine application in intensive care unit patients using mechanical ventilation. Like the esophageal balloon, respiratory muscle electromyography and diaphragmatic ultrasound are minimally invasive tools requiring specific training that monitor respiratory muscle activity. Particularly during the coronavirus disease pandemic, non invasive tools available on mechanical ventilators to monitor respiratory drive, inspiratory effort, and work of breathing have been extended to individualize mechanical ventilation based on patients needs. This review aims to identify the conceptual definitions of respiratory drive, inspiratory effort, and work of breathing and to identify non invasive maneuvers available on intensive care ventilators to measure these parameters. The literature highlights that although respiratory drive, inspiratory effort, and work of breathing are intuitive concepts, even distinguished authors disagree on their definitions.
Los avances tecnológicos de la ventilación mecánica han sido parte esencial del aumento de la sobrevida en las unidades de cuidados intensivos. Desde la conexión a la ventilación mecánica, comúnmente se utiliza ventilación controlada sin la consecuente participación de los músculos respiratorios del paciente, con el fin de favorecer la protección pulmonar. El retiro de la ventilación mecánica implica un periodo de transición hacia la respiración espontánea, utilizando principalmente ventilación mecánica asistida. En esta transición, el desafío de los clínicos es evitar la sub y sobre asistencia ventilatoria, minimizando el esfuerzo respiratorio excesivo, daño diafragmático y pulmonar inducidos por la ventilación mecánica. La monitorización con balón esofágico permite mediciones objetivas de la actividad muscular respiratoria en tiempo real, pero aún hay limitaciones para su aplicación rutinaria en pacientes ventilados mecánicamente en la unidad de cuidados intensivos. Al igual que el balón esofágico, la electromiografía de los músculos respiratorios y la ecografía diafragmática son herramientas que permiten monitorizar la actividad muscular de la respiración, siendo mínimamente invasivas y con requerimiento de entrenamiento específico. Particularmente, durante la actual pandemia de enfermedad por coronavirus se ha extendido el uso de herramientas no invasivas disponibles en los ventiladores mecánicos para monitorizar el impulso (drive), esfuerzo y trabajo respiratorio, para promover una ventilación mecánica ajustada a las necesidades del paciente. Consecuentemente, el objetivo de esta revisión es identificar las definiciones conceptuales de impulso, esfuerzo y trabajo respiratorio utilizadas en el contexto de la unidad de cuidados intensivos, e identificar las maniobras de medición no invasivas disponibles en los ventiladores de cuidados intensivos para monitorizar impulso, esfuerzo y trabajo respiratorio. La literatura destaca que, aunque los conceptos de impulso, esfuerzo y trabajo respiratorio se perciben intuitivos, no existe una definición clara. Asimismo, destacados autores los definen como conceptos diferentes.
Subject(s)
Pandemics , Work of Breathing , Critical Care , Humans , Respiration, Artificial , Ventilators, Mechanical , Work of Breathing/physiologyABSTRACT
BACKGROUND: Physical functioning evaluation in intensive care units (ICUs) identifies rehabilitation requirements and response to interventions. AIM: To identify the usage rate of physical functioning measurement instruments in ICUs during the COVID-19 pandemic in Chile. MATERIAL AND METHODS: Lead physiotherapists representing different national ICUs were invited to answer a National online survey at the onset (T1) and at the first year of COVID-19 pandemic (T2). The usage rate (defined as "always"/"almost always"/"almost never"/"never") of instruments assessing muscle strength, muscle mass, mobility, and physical performance was surveyed. Also, the reasons for selecting these instruments were requested. RESULTS: We received responses from 94 and 93 ICUs at T1 and T2, respectively, of 111 eligible ICUs (55% public). Compared with T2, the usage rate of instruments was lower at T1, and significant only for Medical Research Sum-Score (MRC-SS) (p = 0.04) and handgrip dynamometry (p = 0.05). Considering the answers "always", "almost always" and "almost never", between 89% and 91% of the ICUs reported the use of the MRC-SS; between 70% and 73% reported the use of the Functional Status Score for the Intensive Care Unit; between 5% and 35% of the ICUs reported the use of the rest of mobility scales; and between 44%-45% of ICUs reported that muscle ultrasound was "almost never" used. The main reasons reported for selecting instruments were quick use and clinimetric properties. CONCLUSIONS: The usage rate of muscle strength assessments was frequent, while the use of mobility and muscle mass instruments recommended by the literature was poorly reported, which was lower at the onset of the pandemic.
Subject(s)
COVID-19 , Pandemics , Humans , Hand Strength , Chile/epidemiology , Critical Care , Intensive Care UnitsABSTRACT
Purpose: Evaluate inter-observer reliability of trained physiotherapists administering the Chilean-Spanish version of the Functional Status Score for the Intensive Care Unit (FSS-ICU).Methods: Six adult patients in a medical-surgical ICU were assessed and video-recorded by 1 of 2 expert physiotherapists. Twelve physiotherapists were then trained using recommended Spanish-language FSS-ICU materials. The 12 physiotherapists independently scored the FSS-ICU for the 6 video-recorded patients. Intraclass Correlation Coefficient (ICC) was used to evaluate the inter-observer reliability, and modified Bland-Altman plots evaluated agreement between the physiotherapists and experts.Results: This study was performed between May and August 2018. The FSS-ICU total score had a median score of 18 (range: 6 to 34) for the 6 patients. The ICC of the total score was 0.96 (95% CI, 0.92 to 1.00), and for each of the 5 individual FSS-ICU tasks, the ICC ranged between 0.87 and 0.92. The modified Bland-Altman plot revealed a mean difference of 0.6 (95% limits of agreement: -3.3 to 4.5).Conclusions: Twelve trained physiotherapists had excellent inter-observer reliability when administering the Chilean-Spanish FSS-ICU using videos of six critically ill patients, and had excellent agreement with an expert, revealing differences within the established minimal important difference. These findings provide new data supporting clinimetric properties of the Chilean-Spanish FSS-ICU.
Subject(s)
Physical Therapists , Adult , Functional Status , Humans , Intensive Care Units , Language , Observer Variation , Reproducibility of ResultsABSTRACT
INTRODUCTION: The ongoing pandemic could affect the duration, variety and severity of the mental, physical, and cognitive impairments intensive care unit (ICU) survivors and their families frequently present. We aim to determine the impact of the COVID-19 pandemic on the mental, physical, and cognitive health of survivors, the experience of their families and their treating healthcare professionals. METHODS AND ANALYSIS: Prospective, multicentre, mixed-methods cohort study in seven Chilean ICUs. SAMPLE: 450 adults, able to walk independently prior to admission, in ICU and mechanical ventilation >48 hours with and without COVID-19. Clinical Frailty Scale, Charlson comorbidity index, mobility (Functional Status Score for the Status Score for the Intensive Care Unit) and muscle strength (Medical Research Council Sum Score) will be assessed at ICU discharge. Cognitive functioning (Montreal Cognitive Assessment-blind), anxiety and depression (Hospital Anxiety and Depression Scale), post-traumatic stress (Impact of Event Scale-Revised) symptoms, disability (WHO Disability Assessment Schedule 2.0), quality of life (European Quality of Life Health Questionnaire), employment and survival will be assessed at ICU discharge, 3 months and 6 months. A sample will be assessed using actigraphy and the Global Physical Activity Questionnaire at 6 months after ICU discharge. Trajectories of mental, physical, and cognitive impairments will be estimated using multilevel longitudinal modelling. A sensitivity analysis using multiple imputations will be performed to account for missing data and loss-to-follow-up. Survival will be analysed using Kaplan-Meier curves. The perceptions of family members regarding the ICU stay and the later recovery will be explored 3 months after discharge. Healthcare professionals will be invited to discuss the challenges faced during the pandemic using semistructured interviews. Interviews will be thematically analysed by two independent coders to identify the main themes of the experience of family members and healthcare professionals. ETHICS AND DISSEMINATION: The study was approved by the Clinica Alemana Universidad del Desarrollo Ethics Committee (2020-78) and each participating site. Study findings will be published in peer-reviewed journals and disseminated through social media and conference meetings. TRIAL REGISTRATION NUMBER: NCT04979897.
Subject(s)
COVID-19 , Pandemics , Adult , Cognition , Cohort Studies , Critical Care , Humans , Intensive Care Units , Prospective Studies , Quality of Life , SARS-CoV-2ABSTRACT
OBJECTIVE: To evaluate learning results of critical care physiotherapists participating in a muscle ultrasound (MUS) educational program. DESIGN: Cross-sectional study. SETTING: A custom-made 20-hour MUS course was performed over a 2-week time period, including knobs familiarization, patient positioning, anatomic landmarks, image acquisition, and limb muscle measurements. PARTICIPANTS: Nineteen critical care physiotherapists with little to no prior experience in ultrasound (N=19). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Theoretical knowledge, hands-on skills acquisition, and satisfaction were assessed. Inter- and intrarater reliability on landmarks, thickness, and pennation angle of quadriceps between participants was evaluated using intraclass correlation coefficients (ICCs). Reliability among instructors measured prior to the course was also reported as a reference. RESULTS: The percentage score (mean±SD) of knowledge questionnaires was 69±11 (pre-course), 89±10 (post-course), and 92±9 (hands-on skills). Course satisfaction scores ranged from 90%-100%. Pooled interrater reliability of participants (median ICC [interquartile range]) was good (0.70 [0.59-0.79]) for thickness, moderate (0.47 [0.46-0.92]) for landmarks, and absent (0.00 [0.00-0.05]) for pennation angle and the intrarater reliability was good (0.76 [0.51-0.91]) for thickness and weak (0.35 [0.29-0.52]) for pennation angle. Interrater ICC values for instructors were excellent (0.90) for thickness, good (0.67) for landmarks, and moderate (0.41) for pennation angle and intrarater ICC values were excellent (0.94) for thickness and good (0.75) for pennation angle. CONCLUSIONS: Although our sample was quite small and homogeneous, increased theoretical knowledge, high hands-on performance acquisition, and good satisfaction of physiotherapists were observed. Reliability was moderate to excellent for thickness and landmarks and absent to weak for pennation angle. Landmarking and pennation angle remain challenges for physiotherapist training in the application of MUS. Further studies are needed to identify variables that could modify reliability during MUS training.
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BACKGROUND: Balance disorders are common in patients with neurological or vestibular diseases. Telerehabilitation program is a treatment to be as safe as conventional treatment. One of the most used methods to perform telerehabilitation is the incorporation of Virtual Reality. In general, rehabilitation programs train predictive postural control, so the patient does not always acquire the necessary autonomy to react to situations of instability. On the other hand, the objective and systematic supervision and measurement of these programs is limited, making it necessary to create clinical protocols with precise and measurable rehabilitation objectives. This study present the training selection methodology and clinical protocol for patients with balance disorders inserted in a Telerehabilitation Program based on Virtual Reality. METHODS: Descriptive study where physiotherapists were trained to use RehaMetrics®. To evaluate their level of agreement in the selection of the exercise clusters developed, the Interobserver Reliability was measured through the kappa statistic. Subsequently, the exercises were applied to a group of patients recruited with sedentary trunk control (Berg Balance Scale = 3 points in item 3), mild or normal cognitive level (Montreal Cognitive Assessment> 21 points), and prescribed for tele-rehabilitation by a doctor. RESULTS: The agreement among the expert physiotherapists irrespective of the cluster exceeds 80%, which indicates a very good strength of agreement, while the novices reached a level of agreement of 45%, which suggests a moderate strength of agreement. All clinical outcomes showed statistically significant differences between the median times, as did the Maximum Width Left Side (MWLS) (cm). The average number of minutes of training was 485.81 (SD 246.49 min), and the number of sessions performed during the 4 weeks of intervention was 17 (SD 7.15 sessions). CONCLUSIONS: This analysis what had excellent interobserver reliability with trained physiotherapists. Regarding the second phase of the study, the results show a statistically significant difference between the initial and final evaluation of the clinical tests, which could result in better performance in aspects such as: balance, gait functionality, meter walked and cognition. Telerehabilitation Program based on Virtual Reality is an excellent alternative to provide continuity of treatment to patients with balance disorders.
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BACKGROUND: Prone positioning is a therapy utilized globally to improve gas exchange, minimize ventilator-induced lung injury, and reduce mortality in ARDS, particularly during the ongoing coronavirus disease 2019 (COVID-19) pandemic. Whereas the respiratory benefits of prone positioning in ARDS have been accepted, the concurrent complications could be undervalued. Therefore, this study aimed to identify the adverse events (AEs) related to prone positioning in ARDS and, secondarily, to collect strategies and recommendations to mitigate these AEs. METHODS: In this scoping review, we searched recommendation documents and original studies published between June 2013 and November 2020 from 6 relevant electronic databases and the websites of intensive care societies. RESULTS: We selected 41 documents from 121 eligible documents, comprising 13 recommendation documents and 28 original studies (involving 1,578 subjects and 994 prone maneuvers). We identified > 40 individual AEs, and the highest-pooled occurrence rates were those of severe desaturation (37.9%), barotrauma (30.5%), pressure sores (29.7%), ventilation-associated pneumonia (28.2%), facial edema (16.7%), arrhythmia (15.4%), hypotension (10.2%), and peripheral nerve injuries (8.1%). The reported mitigation strategies during prone positioning included alternate face rotation (18 [43.9%]), repositioning every 2 h (17 [41.5%]), and the use of pillows under the chest and pelvis (14 [34.1%]). The reported mitigation strategies for performing the prone maneuver comprised one person being at the headboard (23 [56.1%]), the use of a pre-maneuver safety checklist (18 [43.9%]), vital sign monitoring (15 [36.6%]), and ensuring appropriate ventilator settings (12 [29.3%]). CONCLUSIONS: We identified > 40 AEs reported in prone positioning ARDS studies, including additional AEs not yet reported by previous systematic reviews. The pooled AE proportions collected in this review could guide research and clinical practice decisions, and the strategies to mitigate AEs could promote future consensus-based recommendations.
Subject(s)
COVID-19 , Respiratory Distress Syndrome , Adult , Humans , Patient Positioning , Prone Position , Respiration, Artificial/adverse effects , Respiratory Distress Syndrome/etiology , Respiratory Distress Syndrome/therapy , SARS-CoV-2ABSTRACT
This scoping review is aimed to summarize current knowledge on respiratory support adjustments and monitoring of metabolic and respiratory variables in mechanically ventilated adult patients performing early mobilization. DATA SOURCES: Eight electronic databases were searched from inception to February 2021, using a predefined search strategy. STUDY SELECTION: Two blinded reviewers performed document selection by title, abstract, and full text according to the following criteria: mechanically ventilated adult patients performing any mobilization intervention, respiratory support adjustments, and/or monitoring of metabolic/respiratory real-time variables. DATA EXTRACTION: Four physiotherapists extracted relevant information using a prespecified template. DATA SYNTHESIS: From 1,208 references screened, 35 documents were selected for analysis, where 20 (57%) were published between 2016 and 2020. Respiratory support settings (ventilatory modes or respiratory variables) were reported in 21 documents (60%). Reported modes were assisted (n = 11) and assist-control (n = 9). Adjustment of variables and modes were identified in only seven documents (20%). The most frequent respiratory variable was the Fio2, and only four studies modified the level of ventilatory support. Mechanical ventilator brand/model used was not specified in 26 documents (74%). Monitoring of respiratory, metabolic, and both variables were reported in 22 documents (63%), four documents (11%) and 10 documents (29%), respectively. These variables were reported to assess the physiologic response (n = 21) or safety (n = 13). Monitored variables were mostly respiratory rate (n = 26), pulse oximetry (n = 22), and oxygen consumption (n = 9). Remarkably, no study assessed the work of breathing or effort during mobilization. CONCLUSIONS: Little information on respiratory support adjustments during mobilization of mechanically ventilated patients was identified. Monitoring of metabolic and respiratory variables is also scant. More studies on the effects of adjustments of the level/mode of ventilatory support on exercise performance and respiratory muscle activity monitoring for safe and efficient implementation of early mobilization in mechanically ventilated patients are needed.
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OBJECTIVE: To evaluate the construct validity (hypotheses testing) of the Chilean-Spanish version of the Functional Status Score for the Intensive Care Unit (FSS-ICU) using continuous actigraphy from intensive care unit (ICU) admission to ICU discharge. DESIGN: The Chilean-Spanish version of the FSS-ICU was used in a prospective observational study to mainly evaluate its correlation with actigraphy variables. The FSS-ICU was assessed on awakening and at ICU discharge, while actigraphy variables were recorded from ICU admission to ICU discharge. SETTING: A 12-bed academic medical-surgical ICU. PARTICIPANTS: Mechanically ventilated patients (N=30), of 92 patients screened. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Construct validity of the FSS-ICU Chilean-Spanish version was assessed by testing 12 hypotheses, including the correlation with activity counts, activity time (>99 counts/min), inactivity time (0-99 counts/min), muscle strength, ICU length of stay, and duration of mechanical ventilation. RESULTS: The median FSS-ICU was 19 points (interquartile range [IQR], 10-26 points) on awakening and 28.5 points (IQR, 22-32 points) at ICU discharge. There was no floor/ceiling effect of the FSS-ICU at awakening (0%/0%) and only a ceiling effect at ICU discharge that was acceptable (0%/10%). Less activity time was associated with better mobility on the FSS-ICU at both awakening (ρ=-0.62, P<.001) and ICU discharge (ρ=-0.79, P<.001). Activity counts and activity time were not correlated as expected with the FSS-ICU. CONCLUSIONS: The Chilean-Spanish FSS-ICU had a strong correlation with inactivity time during the ICU stay. These findings enhance the available clinimetric properties of the FSS-ICU.
Subject(s)
Actigraphy/standards , Disability Evaluation , Functional Status , Intensive Care Units/statistics & numerical data , Respiration, Artificial/statistics & numerical data , APACHE , Aged , Chile , Critical Care Outcomes , Female , Humans , Length of Stay/statistics & numerical data , Male , Middle Aged , Muscle Strength , Patient Discharge/statistics & numerical data , Prospective Studies , Reproducibility of Results , Time FactorsABSTRACT
ANTECEDENTES: El 11 de marzo de 2020, la Organización Mundial de la Salud declaró la enfermedad por coronavirus (COVID-19) como pandemia, cuyos casos y gravedad en Chile han sido elevados. Internacionalmente, los profesionales de la salud han debido adaptar sus actividades laborales hacia pacientes mecánicamente ventilados por agravamiento de los síntomas respiratorios. La terapia respiratoria y terapia física que realizan los kinesiólogos en la unidad de cuidados intensivos (UCI) es fundamental, y existe la urgencia por agrupar datos nacionales que permitan describir la situación y así prepararse para futuros aumentos de la carga asistencial en UCI. OBJETIVO: Describir las modificaciones institucionales, laborales y asistenciales, experimentadas por kinesiólogos que se desempeñan en UCI durante y después de la pandemia COVID-19 en Chile. MÉTODOS: Este es el protocolo de un estudio observacional analítico transversal, el cual recopilará información desde el inicio hasta un año iniciada la pandemia. Se incluirán todas las UCI adulto existentes y las creadas por contingencia COVID-19. Se excluirán aquellas que no hayan recibido pacientes en UCI con COVID-19 confirmado. Se aplicará una encuesta online (REDCap®) al kinesiólogo representante de cada centro, la cual recopilará la información anonimizada principalmente a través de selección múltiple y escala Likert. RESULTADOS ESPERADOS: Se espera identificar un alto porcentaje de modificaciones institucionales en las UCI de Chile, y kinesiólogos que se vieron en la necesidad decambiar sus condiciones laborales y asistenciales durante la pandemia, en comparación al período pre-pandemia;cambios que en un menor porcentaje se mantuvieron en el tiempo.
BACKGROUND: On March 11, 2020, the World Health Organization declared coronavirus disease (COVID-19) as a pandemic, whose cases and severity in Chile have been high. Worldwide, health staffs have adapted their working activities focusing mainly on mechanically ventilated patients due to respiratory decline. Respiratory therapy and physical therapy by physiotherapists in the intensive care unit (ICU) are essential, and national data needs to be collected to describe the pandemic-related context to prepare for future increases in the ICU demand. OBJECTIVE: To describe the institutional, workforce and healthcare modifications experienced by the ICU physiotherapists during and after the COVID-19 pandemic in Chile. METHODS: This is the protocol of a cross-sectional study, which will collect information from the beginning to 1 year after the pandemic begins. All existing adult ICUs and those ICUs created during the pandemic will be included. Those who have not received ICU patients with confirmed COVID-19 will be excluded. An online survey will be applied to the physiotherapists representing each ICU, which will collect the anonymous information mainly through multiple selection-choice and Likert scale.EXPECTED RESULTS: We will be expected to identify a high percentage of institutional modifications in the ICUs in Chile, and that the physiotherapists would need of changing their working and healthcare conditions during the pandemic, compared to the pre-pandemic period; changes that in a smaller percentage would be maintained over time.
