Intensive care unit-acquired weakness (ICUAW) has been recognized as an important and persistent complication in survivors of critical illness. The absence of a consistent nomenclature and diagnostic criteria for ICUAW has made research in this area challenging. Although many risk factors have been identified, the data supporting their direct association have been controversial. Presently, there is a growing body of literature supporting the utility and benefit of early mobility in reducing the morbidity from ICUAW, but few centers have adopted this into their ICU procedures. Ultimately, the implementation of such a strategy would require a shift in the knowledge and culture within the ICU, and may be facilitated by novel technology and patient care strategies. The purpose of this article is to briefly review the diagnosis, risk factors, and management of ICUAW, and to discuss some of the barriers and novel treatments to improve outcomes for our ICU survivors.

Objective

To study the effect of different mail- and phone-based strategies, along with patient- and research-related factors, on the time to contact with research participants.

Study Design and Setting

A prospective evaluation of a 12-week standardized protocol (embedded with two randomized trials of mail- and phone-based strategies) for contacting existing research participants for recruitment into a related study.

Result

Of 146 participants, 87 were eligible for contact via the standardized protocol and 63 (72%) of these were successfully contacted within 12 weeks after multiple mail- and phone-based efforts. Using Cox proportional hazards regression analysis, the different mail and phone strategies showed no significant difference in the time to contact with participants. Of 34 patient- and research-related factors evaluated, only 2 were independently associated with time to contact among all 146 participants: (1) participants having their last visit conducted outside of the research clinic due to patient illness/condition had a longer time to contact; and (2) those with a self-reported chronic fatigue history had a shorter time to contact.

Conclusion

Few patient characteristics and research-related factors accurately predict time to contact. Repeated attempts using different strategies are important to successful and timely contact with study participants.

Background

The Functional Comorbidity Index (FCI) was recently developed to predict physical function in acute lung injury patients using comorbidity data. Our objectives were to determine: (1) the inter-rater reliability of the FCI collected using in-patient discharge summaries (primary objective); and (2) the accuracy and predictive validity of the FCI collected using hospital discharge summaries and admission records versus complete chart review (secondary objectives).

Methods

For reliability, we evaluated the FCI’s intraclass correlation coefficient (ICC) among trained research staff performing data collection for 421 acute lung injury patients enrolled in a prospective cohort study. For validity and accuracy, we compared the detection of FCI comorbidities across three types of inpatient medical records, and the association of the respective FCI scores obtained with patients’ SF-36 physical function subscale (PFS) scores at 1-year follow-up.

Results

Inter-rater reliability was near-perfect (ICC 0.91; 95% CI 0.89-0.94). Hospital admission records and discharge summaries (vs. complete chart review) significantly underestimated the total FCI score. However, using multivariable linear regression, FCI scores collected using each of the three types of inpatient medical records had similar associations with PFS, suggesting similar predictive value.

Conclusions

Data collection using in-patient discharge summaries represents a reliable and valid method for collecting FCI comorbidity information.

Objective

An independent cohort of acute lung injury (ALI) patients was used to evaluate the external validity of a simple prediction model for short-term mortality previously developed using data from ARDS Network (ARDSNet) trials.

Design, Setting, and Patients

Data for external validation were obtained from a prospective cohort study of ALI patients from 13 ICUs at four teaching hospitals in Baltimore, Maryland.

Measurements and Main Results

Of the 508 non-trauma, ALI patients eligible for this analysis, 234 (46%) died in-hospital. Discrimination of the ARDSNet prediction model for inhospital mortality, evaluated by the area under the receiver operator characteristics curves (AUC), was 0.67 for our external validation dataset versus 0.70 and 0.68 using APACHE II and the ARDSNet validation dataset, respectively. In evaluating calibration of the model, predicted versus observed in-hospital mortality for the external validation dataset was similar for both low risk (ARDSNet model score = 0) and high risk (score = 3 or 4+) patient strata. However, for intermediate risk (score = 1 or 2) patients, observed in-hospital mortality was substantially higher than predicted mortality (25.3% vs. 16.5% and 40.6% vs. 31.0% for score = 1 and 2, respectively). Sensitivity analyses limiting our external validation data set to only those patients meeting the ARDSNet trial eligibility criteria and to those who received mechanical ventilation in compliance with the ARDSNet ventilation protocol, did not substantially change the model’s discrimination or improve its calibration.

Conclusions

Evaluation of the ARDSNet prediction model using an external ALI cohort demonstrated similar discrimination of the model as was observed with the ARDSNet validation dataset. However, there were substantial differences in observed versus predicted mortality among intermediate risk ALI patients. The ARDSNet model provided reasonable, but imprecise, estimates of predicted mortality when applied to our external validation cohort of ALI patients.

A 44-year-old morbidly obese (body mass index 69 kg/m2) woman presented to our medical intensive care unit (ICU) with septic shock and multiorgan failure requiring mechanical ventilation, a vasopressor infusion, and haemodialysis. Before this admission, the patient reported being able to ambulate approximately 3 m with a walker. Intensive physical therapy was started on ICU day 2, and the patient was successfully mobilised throughout her ICU stay despite the extreme challenges posed by her morbid obesity and critical illness. After only a 9 day stay, the patient was discharged directly home from the medical ICU, walking a total distance of 37 m in a single physical therapy session.

Objective

The goal of the paper is to determine inter-rater reliability of trained examiners performing standardized strength assessments using manual muscle testing (MMT).

Design, subjects, and setting

The authors report on 19 trainees undergoing quality assurance within a multi-site prospective cohort study.

Intervention

Inter-rater reliability for specially trained evaluators (“trainees”) and a reference rater, performing MMT using both simulated and actual patients recovering from critical illness was evaluated.

Measurements and results

Across 26 muscle groups tested by 19 trainee-reference rater pairs, the median (interquartile range) percent agreement and intraclass correlation coefficient (ICC; 95% CI) were: 96% (91, 98%) and 0.98 (0.95, 1.00), respectively. Across all 19 pairs, the ICC (95% CI) for the overall composite MMT score was 0.99 (0.98–1.00). When limited to actual patients, the ICC was 1.00 (95% CI 0.99–1.00). The agreement (kappa; 95% CI) in detecting clinically significant weakness was 0.88 (0.44–1.00).

Conclusions

MMT has excellent inter-rater reliability in trained examiners and is a reliable method of comprehensively assessing muscle strength.

Scarce resources may cause doctors to be pessimistic about prognosis and refuse critical care admissions

Many studies have demonstrated that closed intensive care units (ICUs), staffed by trained intensivists, are associated with improved patient outcomes. However, the mechanisms by which ICU organizational factors, such as physician staffing, influence patient outcomes are unclear. One potential mechanism is the increased utilization of evidence-based practices in closed ICUs. Cooke and colleagues investigated this hypothesis in a cohort of 759 acute lung injury patients in 23 ICUs in King County, Washington, USA. Although closed ICUs were independently associated with a modestly lower mean tidal volume, this finding did not explain the mortality benefit associated with a closed ICU model in this patient cohort. Future studies should evaluate other potential mechanisms by which closed ICUs improve patient outcomes. An improved understanding of these mechanisms may yield new targets for improving the quality of medical care for all ICU patients.

As the mortality from critical illness has improved in recent years, there has been increasing focus on patient outcomes after hospital discharge. Neuromuscular weakness acquired in the intensive care unit (ICU) is common, persistent, and often severe. Immobility due to prolonged bed rest in the ICU may play an important role in the development of ICU-acquired weakness. Studies in other patient populations have demonstrated that moderate exercise is beneficial in altering the inflammatory milieu associated with immobility, and in improving muscle strength and physical function. Recent studies have demonstrated that early mobility in the ICU is safe and feasible, with a potential reduction in short-term physical impairment. However, early mobility requires a significant change in ICU practice, with reductions in heavy sedation and bed rest. Further research is required to determine whether early mobility in the ICU can improve patients' short-term and long-term outcomes.

Steroid use in critically ill, vasopressor-dependant, septic patients has gained increased acceptance in recent years with the publication of encouraging data. However, with renewed interest and/or attention comes increased debate and analysis. As a result, it is not surprising to find that there is still significant controversy with regards to the role of steroids in many patients. In this article, two expert groups debate the role of steroid use in a septic shock patient with arguably no clear evidence of adrenal insufficiency.

Introduction

We aimed to determine the adverse events and important prognostic factors associated with interfacility transport of intubated and mechanically ventilated adult patients.

Methods

We performed a systematic review of MEDLINE, CENTRAL, EMBASE, CINAHL, HEALTHSTAR, and Web of Science (from inception until 10 January 2005) for all clinical studies describing the incidence and predictors of adverse events in intubated and mechanically ventilated adult patients undergoing interfacility transport. The bibliographies of selected articles were also examined.

Results

Five studies (245 patients) met the inclusion criteria. All were case-series and two were prospective in design. Due to the paucity of studies and significant heterogeneity in study population, outcome events, and results, we synthesized data in a qualitative manner. Pre-transport severity of illness was reported in only one study. The most common indication for transport was a need for investigations and/or specialist care (three studies, 220 patients). Transport modalities included air (fixed or rotor wing; 66% of patients) and ground (31%) ambulance, and commercial aircraft (3%). Transport teams included a physician in three studies (220 patients). Death during transfer was rare (n = 1). No other adverse events or significant therapeutic interventions during transport were reported. One study reported a 19% (28/145) incidence of respiratory alkalosis on arrival and another study documented a 30% overall intensive care unit mortality, while no adverse events or outcomes were reported after arrival in the three other studies.

Conclusion

Insufficient data exist to draw firm conclusions regarding the mortality, morbidity, or risk factors associated with the interfacility transport of intubated and mechanically ventilated adult patients. Further study is required to define the risks and benefits of interfacility transfer in this patient population. Such information is important for the planning and allocation of resources related to transporting critically ill adults.

Intravascular fluid therapy is a common critical care intervention. However, the optimal type of resuscitation fluid, crystalloid or colloid, remains controversial. Despite the many theoretical benefits of human albumin administration in critically ill patients, there has been little evidence to support its widespread clinical use. Previous systematic reviews have led to conflicting results regarding the safety and efficacy of albumin. The recently reported Saline versus Albumin Evaluation study has provided conclusive evidence that 4% albumin is as safe as saline for resuscitation, although no overall benefit of albumin use was seen. Subgroup analysis of the albumin-treated group revealed a trend towards decreased mortality in patients with septic shock, and a trend towards increased mortality in trauma patients, especially those with traumatic brain injury. The results of these subgroups, as well as the use of higher albumin concentrations and other synthetic colloids (dextrans, starches), require rigorous evaluation in clinical trials. Finally, the Saline versus Albumin Evaluation trial represents a methodological milestone in critical care medicine, due to its size, its efficient trial design, and its logistical coordination. Future studies are still required, however, to establish a therapeutic niche for albumin and other colloids.