Risk factors associated with the development of delirium in general ICU patients. A prospective observational study.

OBJECTIVE: We aimed to analyze risk factors related to the development of delirium, aiming for early intervention in patients with greater risk. MATERIAL AND METHODS: Observational study, including prospectively collected patients treated in a single general ICU. These were classified into two groups, according to whether they developed delirium or not (screening performed using CAM-ICU tool). Demographics and clinical data were analyzed. Multivariate logistic regression analyses were performed to quantify existing associations. RESULTS: 1462 patients were included. 93 developed delirium (incidence: 6.3%). These were older, scored higher on the Clinical Frailty Scale, on the risk scores on admission (SAPS-3 and SOFA), and had a greater number of organ failures (OF). We observed more incidence of delirium in patients who (a) presented more than two OF (20.4%; OR 4.9; CI95%: 2.9-8.2), and (b) were more than 74 years old albeit having <2 OF (8.6%; OR 2.1; CI95%: 1.3-3.5). Patients who developed delirium had longer ICU and hospital length-of-stays and a higher rate of readmission. CONCLUSIONS: The highest risk observed for developing delirium clustered in patients who presented more than 2 OF and patients over 74 years old. The detection of patients at high risk for developing delirium could imply a change in management and improved quality of care.

Homeward Bound: A Case Series of Cross-Cultural Care at End of Life, Enhanced by Pediatric Palliative Transport.

For most families, the preferred location of death for their child is home, yet most children still die in the hospital. Many children with life-threatening and life-limiting illness are medically dependent on technology, and palliative transport can serve as a bridge from the intensive care unit to the family's home to achieve family-centered goals of care. Palliative transport may also present an opportunity to prioritize cultural care and rituals at end of life which cannot be provided in the hospital. We describe a case series of pediatric patients from communities espousing markedly diverse cross-cultural values and limited financial resources. Specific cultural considerations at end of life for these children included optimizing the presence of the shared community or tribe, the centrality of healing rituals, and varied attitudes toward withdrawal of life-sustaining medical treatment. By addressing each of these components, we were able to coordinate palliative transport to enhance cross-cultural care and meaning at end of life for children with life-limiting illness.

Reasons for requesting medical assistance in dying.

OBJECTIVE: To review the charts of people who requested medical assistance in dying (MAID) to examine their reasons for the request. DESIGN: Retrospective chart survey. SETTING: British Columbia. PARTICIPANTS: Patients who requested an assisted death and were assessed by 1 of 6 physicians in British Columbia during 2016. MAIN OUTCOME MEASURES: Patients' diagnoses and reasons for requesting MAID. RESULTS: Data were collected from 250 assessments for MAID: 112 of the patients had assisted deaths, 11 had natural deaths, 35 were assessed as not eligible for MAID, and most of the rest were not ready. For people who had assisted deaths, disease-related symptoms were given as the first or second most important reason for requesting assisted death by 67 people (59.8%), while 59 (52.7%) gave loss of autonomy, 55 (49.1%) gave loss of ability to enjoy activities, and 27 (24.1%) gave fear of future suffering. People who were assessed as eligible but who had not received assisted deaths were more likely to list fear of future suffering (33.7% vs 7.1%) and less likely to list disease-related symptoms (17.4% vs 40.2%) than those who received MAID were. There was a difference in reasons for MAID given by people with different diagnoses; disease-related symptoms were given as the most important reason by 39.0% of patients with malignancies, 6.8% of patients with neurological diseases, and 28.9% of patients with end-organ failure. Loss of autonomy was given as the most important reason by 16.0% of patients with malignancies, 36.4% of patients with neurological diseases, and 23.7% of patients with end-organ failure. CONCLUSION: This study shows that the reasons patients give for requesting an assisted death are similar to those reported in other jurisdictions with similar laws, but in different proportions. Loss of autonomy and loss of ability to enjoy activities were less common reasons among patients in this study compared with other jurisdictions. This might be related to the method of data collection, as in this study, the patients' reasons were recorded by physicians.

The long-term quality of life in patients with persistent inflammation-immunosuppression and catabolism syndrome after severe acute pancreatitis: A retrospective cohort study.

PURPOSE: To explore clinical characteristics and long-term quality of life (QOL) in severe acute pancreatitis (SAP) patients with persistent inflammation-immunosuppression and catabolism syndrome (PICS). MATERIALS AND METHODS: SAP patients admitted to ICU were eligible for the retrospective cohort study if they needed prolonged intensive care (>14days). Post-ICU QOL was assessed by a questionnaire, including 36-item Short Form Health Survey (SF-36) and record of re-work in a long-term follow-up. RESULTS: 214 SAP patients were enrolled, in which 149 (69.6%) patients met the criteria of PICS. PICS patients had more complications and ICU days compared to non-PICS patients (P<0.001), and their post-ICU mortality was higher (P=0.046). When adjusted for confounders, PICS was independently associated with higher post-ICU mortality (hazard ratio 4.5; 95% CI, 1.2 to 16.3; P=0.024). The 36-item Short Form Health Survey (SF-36) score was lower for PICS group in six subscales (P<0.001). Only 28.8% patients in the PICS group returned to work compared to 60% patients in the non-PICS group (P=0.001) CONCLUSIONS: SAP patients with prolonged ICU stay had a high morbidity of PICS, which was a risk factor for the post-ICU mortality and poor long-term QOL.

[Heart Failure - A Model for Multimorbidity]. / Herzinsuffizienz ­ ein Modell für Multimorbidität.

Heart failure frequently is the consequence of different cardiac diseases and is associated with multiple cardiac and non-cardiac co-morbidities. It may be exemplary for multi-morbidity in the elderly, has negative impact on various organ systems and may induce further comorbidities. The following article addresses heart failure as a multisystem disorder.

Clinical residual symptomatology and associated factors in multiple organ failure survivors: A long-term mortgage. / Sintomatología clínica residual y factores asociados en supervivientes de un fracaso multiorgánico: una hipoteca a largo plazo.

PURPOSE: To evaluate which residual clinical symptoms multi-organ failure (MOF) patients may exhibit post discharge from Intensive Care Units (ICU) and to identify the associated factors that cause such symptoms. MATERIAL AND METHODS: A total of 545 adult patients admitted to a medical & surgical ICU in Spain diagnosed with MOF on admission were included in the study. Follow up in the form of a telephone survey regarding the patients clinical symptoms were conducted at 6 and 12 months after discharge from ICU. RESULTS: A total of 266 patients were followed up at both 6 and 12 months post ICU discharge; 62.2% were male; age 60±18 years; 67.8% medical patients. The most common symptoms to appear following hospital discharge included: asthenia (173; 76%), sleep disturbances (112; 50%) and depression (109; 48%). CONCLUSIONS: The study revealed frequent residual clinical symptoms persisting for almost a year post ICU discharge, most notably arthromyalgia and asthenia. Depression symptoms during the first 6 months post-hospital discharge were also common among multiple organ failure survivors. The presence of symptomatology over time was found to be related to a poor functional situation at 6 and12 months post ICU discharge, length of hospital stay and severity of illness score on ICU admission.

Symptom distress in advanced chronic organ failure: disagreement among patients and family caregivers.

BACKGROUND: Proxy reporting is frequently used to assess symptom distress of patients with advanced chronic organ failure. The aim of the present cross-sectional study was to examine agreement in severity of symptom distress, presence of symptom-related interventions, and satisfaction with medical treatment among patients with advanced chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF) and chronic renal failure (CRF) and their family caregivers. METHODS: Outpatients with advanced COPD (n=73), CHF (n=45) and CRF (n=41) and their family caregivers rated severity of physical and psychological symptoms experienced by the patient using Visual Analogue Scales (VAS). The presence of symptom-related interventions was recorded by patients and family caregivers. Finally, patients and family caregivers rated satisfaction with medical treatment of the patient using VAS. Agreement was determined using intraclass correlation coefficients (ICC) for continuous variables and Cohen's kappa for categorical variables. RESULTS: Family caregivers reported a higher number of symptoms than patients (mean [standard deviation; SD]: 8.2 [3.5] versus 7.3 [3.6], respectively [p<0.0005]). For most symptoms, agreement about severity between patients and family caregivers was moderate (ICC: 0.41-0.60). Agreement about satisfaction with medical treatment was fair (ICC [95% confidence interval; CI]: 0.21 [0.05-0.35]). Agreement was poor to moderate for presence of symptom-related interventions (kappa: -0.03-0.54). CONCLUSIONS: Studies using proxy reporting reflect the views of proxies and do not accurately represent the patients' experience. For clinical care, it's important to pay attention to the perception from the patient as well as the perception from the family caregiver of symptom distress, presence of symptom-related interventions, and satisfaction with treatment.

The Toronto prehospital hypertonic resuscitation-head injury and multi organ dysfunction trial (TOPHR HIT)--methods and data collection tools.

BACKGROUND: Clinical trials evaluating the use of hypertonic saline in the treatment of hypovolemia and head trauma suggest no survival superiority over normal saline; however subgroup analyses suggest there may be a reduction in the inflammatory response and multiorgan failure which may lead to better survival and enhanced neurocognitive function. We describe a feasibility study of randomizing head injured patients to hypertonic saline and dextran vs. normal saline administration in the out of hospital setting. METHODS/DESIGN: This feasibility study employs a randomized, placebo-controlled design evaluating normal saline compared with a single dose of 250 ml of 7.5% hypertonic saline in 6% dextran 70 in the management of traumatic brain injuries. The primary feasibility endpoints of the trial were: 1) baseline survival rates for the treatment and control group to aid in the design of a definitive multicentre trial, 2) randomization compliance rate, 3) ease of protocol implementation in the out-of-hospital setting, and 4) adverse event rate of HSD infusion.The secondary objectives include measuring the effect of HSD in modulating the immuno-inflammatory response to severe head injury and its effect on modulating the release of neuro-biomarkers into serum; evaluating the role of serum neuro-biomarkers in predicting patient outcome and clinical response to HSD intervention; evaluating effects of HSD on brain atrophy post-injury and neurocognitive and neuropsychological outcomes. DISCUSSION: We anticipate three aspects of the trial will present challenges to trial success; ethical demands associated with a waiver of consent trial, challenging follow up and comprehensive accurate timely data collection of patient identifiers and clinical or laboratory values. In addition all the data collection tools had to be derived de novo as none existed in the literature. TRIAL REGISTRATION NUMBER: NCT00878631.

Building trustworthy relationships with critically ill patients and families.

A difficult case study involving repeated health crises and irreversible organ dysfunction illustrates the challenges critical care professionals face in caring for patients and their families. In such cases, trust is especially fragile, and coexists with its counterpart, betrayal. The Reina Trust & Betrayal Model defines 3 types of Transactional Trust. The first, Competence Trust, or the Trust of Capability, requires that clinicians practice humility, engage in inquiry, honor the patient's choices, and express compassion. The second, Contractual Trust, or the Trust of Character, demands that clinicians keep agreements, manage expectations, establish boundaries, and encourage mutually serving expectations. The third, Communication Trust, or the Trust of Disclosure, must be rooted in respect and based on truth-telling. Particularly in life-and-death situations, communication requires honesty and clarity. Each type of trust involves specific behaviors that build trust and can guide critical care professionals as they interact with patients and their families.

Psychotic symptoms in patients undergoing coronary artery bypass grafting and heart valve operation.

OBJECTIVE: Delirium on internal medicine and surgical wards of the general hospital is associated with several predisposing and precipitating factors as well as adverse outcomes. Whether psychosis, the symptom of delirium that may be recognized most promptly, is similarly associated with these factors and outcomes is largely unknown. METHODS: Eight thousand one hundred and thirty-nine consecutive patients undergoing coronary artery bypass grafting and/or heart valve operation were screened for preoperative predisposing factors and postoperative psychotic symptoms between January 1999 and July 2004. Data on per- and postoperative precipitating factors were collected in 4942 patients enrolled between January 2001 and July 2004. Data were examined using logistic regression to estimate odds ratios. RESULTS: The rate of severe psychotic symptoms was 2.1% (n=168). Higher age, renal failure, dyspnoea, heart failure, and left ventricle hypertrophy were independent preoperative predisposing factors. Peroperative hypothermia (<33 degrees C), hypoxemia, low hematocrit, renal failure, increased sodium, infection and stroke were independent precipitating factors. Psychotic symptoms were independently associated with a prolonged length of stay on the intensive care unit (odds ratio 7.8; 95% confidence interval 5.6-11), multi-organ failure or shock (3.2; 95% CI: 2.2-4.9), cardiopulmonary resuscitation (3.6; 95% CI: 2.1-6.2), and in-hospital death after surgery (2.1; 95% CI: 1.1-4.1). CONCLUSIONS: Psychotic symptoms are independently associated with several chronic and peroperative problems (including mild hypothermia during surgery), closely resembling those for delirium (with and without psychotic symptoms). Psychotic symptoms are also independently associated with adverse outcomes. Prompt diagnostic and therapeutic intervention aimed at the underlying problem may improve outcomes.

The intimacy of dying: a personal reflection.

Nurses are often involved in patient care at the patient's end of life. The author describes how a nurse's actions can make a positive difference in one person's life, and in one person's death. Using all of the skills and gifts that nurses have to preserve life is a privilege and a challenge; using all of the skills and gifts nurses have to provide a respectful, dignified, peaceful, and even intimate death, is an equal privilege and challenge.

Health-related quality of life before, 1 month after, and 9 months after intensive care in medical cardiovascular and pulmonary patients.

OBJECTIVE: Assessment of health-related quality of life before, 1 month after, and 9 months after an intensive care unit stay using an established generic instrument, the Medical Outcome Survey Short Form-36 (SF-36). DESIGN: Prospective, observational study. SETTING: University hospital medical intensive care unit. PATIENTS: Two hundred forty-five patients with predominantly cardiovascular and pulmonary disorders. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic data, Simplified Acute Physiology Score (SAPS) II, and Sepsis-Related Organ Failure Assessment (SOFA) were obtained. All adult survivors staying in the intensive care unit for >24 hrs were eligible. Pre-intensive care unit status was obtained for 245 patients (179 males, mean age 64 yrs, mean intensive care unit stay 3 days, SAPS II 26 +/- 10), and 153 patients completed all three questionnaires. In this cohort, none of the eight health dimensions of the SF-36 showed impaired functioning after 9 months compared with baseline values. Physical and emotional role deteriorated after 1 month but returned to baseline thereafter. Notably, the mental health summary scale did not change during the course of the study, whereas the physical health summary scale consistently improved over time. Patients older than the median of 66 yrs rated their physical functioning lower. No association with SAPS II or SOFA and SF-36 was found. CONCLUSION: Quality of life after intensive care unit is a dynamic process, with some functions improving shortly after intensive care unit discharge and others deteriorating but returning at least to baseline values later on. In this patient population, the SF-36 was independent from measures of severity of illness or morbidity. Health-related quality of life represents a feasible method to collect patients' individual views in contrast to surrogate measures of outcome.

Health-related quality of life of multiple organ dysfunction patients one year after intensive care.

OBJECTIVE: To assess the quality of life (QOL) of intensive care survivors 1 year after discharge with special emphasis on multiple organ dysfunction (MOD). DESIGN: Prospective, observational study. SETTING: A ten-bed medical-surgical intensive care unit in a tertiary care hospital. PATIENTS: Among the 591 consecutive patients admitted in the year 1995, 307 of 378 patients who survived 1 year were studied. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: A generic scale assessing health-related QOL, the RAND 36-item Health Survey (RAND 36) was sent by mail 12 months after discharge. Data concerning age, severity of illness, organ dysfunctions and diagnoses were recorded. Of 307 patients, 98 (31.9 %) were able to work. The QOL measured by the RAND 36 showed clinically relevant impairment in emotional and physical role limitations compared with an age- and sex-matched general population. MOD (n = 131, 42.7 %) had a statistically significant negative effect on all QOL domains, except bodily pain and mental health, with the only clinically relevant impairment being in vitality and emotional role limitations compared with non-MOD patients. Of the 131 MOD patients, 36 (27.4 %) were able to work, 26 (19.8%) had severe limitations in their daily activities and 5 (3.8 %) were unable to live at home 1 year after discharge. CONCLUSIONS: One year after intensive care the survivors had a lower QOL than an age-matched general population with clinically relevant further impairment of MOD patients in vitality and emotional role limitations.

Dying with acute respiratory failure or multiple organ system failure with sepsis.

BACKGROUND: The dying experience of patients with acute respiratory failure (ARF) or multiple organ system failure with sepsis (MOSF) has not been described. OBJECTIVES: To describe patients dying from ARF or MOSF, including demographic characteristics, baseline function and quality of life, symptoms, preferences, use of life-sustaining treatments, satisfaction with care, and family burden. DESIGN: A multicenter prospective study. SETTING: Five US teaching hospitals, in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). PARTICIPANTS: A total of 1295 adults who died during hospitalization for ARF or MOSF. MEASUREMENTS: Chart reviews and interviews with patients and surrogates. RESULTS: SUPPORT enrolled 2956 patients with ARF or MOSF, and 44% died during enrollment hospitalization. Quality of life before hospitalization was reported as fair by 87% of patients. The mean number of impairments in their baseline activities of daily living was 1.6. At the time of death, 79% had a DNR order and 31% had an order to withhold ventilator support. The average time from the DNR order to death was 2 days. Dying patients spent an average of 9 days on a ventilator. Surrogates indicated that one out of four patients died with severe pain and one out of three with severe confusion. Families of 42% of the patients who died reported one or more substantial burden. CONCLUSIONS: Patients in this study reported substantial functional impairments and reduced quality of life. Limitations to aggressive treatments were usually implemented only when death was imminent. Family impact and physical and emotional suffering were substantial.

Emergency intravenous sedation of the delirious, medically ill patient.

More than 2,000 medically ill patients with delirium have been treated by intravenous administration of a combination of haloperidol and lorazepam. The protocol was developed over 8 years at two major cancer centers in the United States and Canada. The addition of the potent benzodiazepine to the neuroleptic produces rapid and safe symptomatic sedation in emergency conditions and allows the use of lower doses of haloperidol. The combination was first attempted when doses of haloperidol as high as 350 mg failed to provide rapid emergency neurobehavioral control. All patients treated to date had cancer, and all were suffering multisystem organ failure. Hourly doses of each drug as high as 10 mg for as long as 15 days have been shown to be safe and effective in the most critically ill patient with delirium. Patients generally respond to the first one or two doses and, in most cases, less than 100 mg/day of each drug is required. The addition of the opioid hydromorphone makes the combination ideal for the treatment of intractable pain in terminally ill cancer patients. This polypharmacological approach is advocated as the method of choice for emergency sedation of the delirious patient as well as for palliative care.