Survivors of Acute Lung Injury Have Greater Impairments in Strength and Exercise Capacity Than Survivors of Other Critical Illnesses as Measured Shortly After ICU Discharge.

PURPOSE: To compare the physical function on ICU discharge in adults who survived an ICU admission for acute lung injury (ALI) with those admitted for a critical illness other than ALI. MATERIALS AND METHODS: Two groups were recruited, (i) those who survived an ICU admission for ALI and, (ii) those who survived an ICU admission for a critical illness other than ALI. Within 7 days of discharge from ICU, in all participants, measures were collected of peripheral muscle strength, balance, walking speed and functional exercise capacity. RESULTS: Recruitment was challenging and ceased prior to achieving the desired sample size. Participants with ALI (n = 22) and critical illness (n = 33) were of similar median age (50 vs. 57 yr, p = 0.09), sex proportion (males %, 45 vs. 58, p = 0.59) and median APACHE II score (21.5 vs. 23.0, p = 0.74). Compared with the participants with critical illness, those with ALI had lower hand grip (mean ± SD, 18 ± 9 vs. 13 ± 8 kg, p = 0.018) and shoulder flexion strength (10 ± 4 vs. 7 ± 3 kg, p = 0.047), slower 10-meter walk speed (median [IQR], 1.03 [0.78 to 1.14] vs. 0.78 [0.67 to 0.94] m/s, p = 0.039) and shorter 6-minute walk distance (265 [71 to 328] vs. 165 [53 to 220] m, p = 0.037). The Berg balance scores were similar in both groups. CONCLUSIONS: Compared with survivors of a critical illness that is not ALI, those with ALI are likely to have greater physical impairment when measured shortly after discharge to the ward.

Abnormal Exercise Responses in Survivors of Acute Lung Injury During Cardiopulmonary Exercise Testing: AN OBSERVATIONAL STUDY.

PURPOSE: This study compared exercise responses in individuals who had recently survived an admission to the intensive care unit for acute lung injury (ALI) with healthy controls. METHODS: Ten patients with ALI were recruited at 2 Australian hospitals. Six weeks after hospital discharge, participants completed lung function measures and a laboratory-based cardiopulmonary exercise test. Identical measures were collected in 21 healthy participants of similar age and gender distribution. RESULTS: Compared with the healthy participants, the ALI participants were similar in age (51 ± 14 vs 50 ± 16 yr), with a lower peak oxygen uptake ((Equation is included in full-text article.)O2) (median [interquartile range], 31.80 [26.60-41.73] vs 17.80 [14.85-20.85] mL/kg/min; P < .01) and higher ventilatory equivalent for carbon dioxide ((Equation is included in full-text article.)E/(Equation is included in full-text article.)CO2) at anaerobic threshold (mean ± SD, 25.7 ± 2.5 vs 35.2 ± 4.1; P < .01). Analysis of individual ALI participant responses showed that 8 participants had a decreased peak (Equation is included in full-text article.)O2 and anaerobic threshold. All ALI participants were limited by leg fatigue. Abnormalities of pulmonary gas exchange were present in 7 participants. Evidence of cardiac ischemia was present in 2 participants. CONCLUSIONS: Compared with healthy controls, ALI participants had reduced exercise capacity, mainly due to profound deconditioning. Exercise training to optimize aerobic capacity would appear to be a rehabilitation priority in this population.

The effects of introduction of new observation charts and calling criteria on call characteristics and outcome of hospitalised patients.

OBJECTIVE: To determine the impact on call characteristics and patient outcomes since the implementation of a two-tiered rapid-response system along with new observation charts and calling criteria. DESIGN AND SETTING: A retrospective before-and-after study in an Australian tertiary referral hospital. PARTICIPANTS: Consecutive adult patients (_18 years), who had a rapid-response call between June and October 2009 ("before") and between June and October 2010 ("after"). MAIN OUTCOME MEASURES: Incidence of "serious adverse events" (cardiac arrests, unexpected deaths, and unplanned intensive care unit/high-dependency unit [HDU] admissions); subsequent illness severity and ICU/HDU and hospital mortality and length of stay; episodes of repeat calls for the same patient, time since admission and treatment limitation/ not-for-resuscitation order profiles. RESULTS: Statistically significant increase in number of rapid response calls from 14.3 to 21.2 per 1000 hospital admissions before and after, respectively (P < 0.001); this was associated with a 16% decrease in composite serious adverse events (not significant). There were no significant differences in the number of unplanned ICU/HDU admissions, admission severity scores and subsequent ICU/HDU and hospital mortality and length of stay. There was a significant increase in number of calls for patients who were admitted to hospital within 24 hours (2.5 v 4.7 per 1000 hospital admissions before and after, respectively; P < 0.05) and for patients who were transferred from acute care areas within 24 hours (3.7 v 6.2 per 1000 hospital admissions before and after, respectively; P < 0.05). There was a significant increase in number of repeat calls for the same patient (1.6 v 4.2 per 1000 hospital admissions before and after, respectively; P < 0.001); this was associated with higher mortality compared with single review in the after period (35.8% v 18.5%, respectively; P = 0.005). CONCLUSIONS: Implementation of a two-tiered rapid-response system and new observation charts and calling criteria increased the number of rapid-response calls with a nonsignificant trend towards a decreased incidence of serious adverse events. Further improvements in care of hospitalised patients may be possible by preventing repeat calls or calls within 24 hours of hospital admission and discharge from acute care areas.

Mission to eliminate postinjury abdominal compartment syndrome.

OBJECTIVES: To determine the current incidence of postinjury abdominal compartment syndrome (ACS), the effect of intra-abdominal hypertension (IAH) on trauma outcomes, and the independent predictors of postinjury IAH. DESIGN: Prospective cohort study. SETTING: University-affiliated level 1 trauma center. PATIENTS: Eighty-one consecutive shock/trauma patients admitted to the intensive care unit (mean [SD] values: age, 41 [2] years; 70% male; injury severity score, 29 [1]; base deficit, 6 [0.5] mmol/L; lactate level, 29.73 [4.5] mg/dL; transfusions of packed red blood cells, 5 [0.5] U in first 24 hours; mortality rate, 2.5%; and multiple organ failure [MOF], 6%) had second hourly intra-abdominal pressure (IAP) monitoring. MAIN OUTCOME MEASURES: Intensive care unit length of stay, ACS, IAH, MOF, mortality. RESULTS: The mean (SD) IAP was 14 (1) mm Hg. No patients developed ACS. Sixty-one patients (75%) had sustained IAH. Both patients with IAH and those without had similar demographics and injury severity. Patients with IAH had worse metabolic acidosis (P = .02), received more crystalloids (P = .03), and underwent laparotomy more frequently (P = .005). One patient with IAH and one without died. MOF occurred in 1 patient without IAH (5%) vs 4 with IAH (7%). The mean (SD) intensive care unit length of stay was 11 (3) days in patients without IAH vs 8 (1) days in those with IAH. Intra-abdominal hypertension was poorly predictive of MOF (odds ratio, 1.17; 95% confidence interval, 0.96-1.43; P = .13). Of the 30 variables in multiple logistic regression analysis, only base deficit, laparotomy, and emergency department crystalloids were identified as weak predictors of IAP greater than 12 mm Hg. No predictors were found for the clinically more relevant IAP greater than 15 mm Hg and IAP greater than 18 mm Hg. CONCLUSIONS: Most of the severe shock/trauma patients developed sustained IAH. Based on univariate and multivariate analyses, there was no difference in outcomes between the trauma patients with IAH and those without. Multiple logistic regression analysis failed to show IAH as a predictor of MOF. The attenuation of the deadly ACS to a less deleterious IAH could be considered a success of the last decade in trauma and critical care.