Journal of Clinical Medicine

Editorial

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3 pages, 201 KiB

Open AccessEditorial

Post-Intensive Care Syndrome after Critical Illness: An Imperative for Effective Prevention

by Nicolas Paul and Björn Weiss

J. Clin. Med. 2022, 11(20), 6203; https://doi.org/10.3390/jcm11206203 - 21 Oct 2022

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Abstract

Over the last decades, the importance of intensive care has considerably increased [...] Full article

(This article belongs to the Special Issue Enhancing Recovery after Intensive Care Medicine in Clinical Practice)

Research

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12 pages, 1152 KiB

Open AccessArticle

The Impact of Non-Pharmacological Interventions on Delirium in Neurological Intensive Care Unit Patients: A Single-Center Interrupted Time Series Trial

by Paul J. T. Rood, Dharmanand Ramnarain, Annemarie W. Oldenbeuving, Brenda L. den Oudsten, Sjaak Pouwels, Lex M. van Loon, Steven Teerenstra, Peter Pickkers, Jolanda de Vries and Mark van den Boogaard

J. Clin. Med. 2023, 12(18), 5820; https://doi.org/10.3390/jcm12185820 - 7 Sep 2023

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Abstract

Background: Delirium is a pathobiological brain process that is frequently observed in Intensive Care Unit (ICU) patients, and is associated with longer hospitalization as well as long-term cognitive impairment. In neurological ICU patients, delirium may be more treatment-resistant due to the initial [...] Read more.

Background: Delirium is a pathobiological brain process that is frequently observed in Intensive Care Unit (ICU) patients, and is associated with longer hospitalization as well as long-term cognitive impairment. In neurological ICU patients, delirium may be more treatment-resistant due to the initial brain injury. This study examined the effects of a multicomponent non-pharmacological nursing intervention program on delirium in neurological ICU patients. Methods: A single-center interrupted time series trial was conducted in adult neurological ICU patients at high risk for developing delirium who were non-delirious at admission. A multicomponent nursing intervention program focusing on modifiable risk factors for delirium, including the optimalization of vision, hearing, orientation and cognition, sleep and mobilization, was implemented as the standard of care, and its effects were studied. The primary outcome was the number of delirium-free and coma-free days alive at 28 days after ICU admission. The secondary outcomes included delirium incidence and duration, ICU and hospital length-of-stay and duration of mechanical ventilation. Results: Of 289 eligible patients admitted to the ICU, 130 patients were included, with a mean age of 68 ± 11 years, a mean APACHE-IV score of 79 ± 25 and a median predicted delirium risk (E-PRE-DELIRIC) score of 42 [IQR 38–50]). Of these, 73 were included in the intervention period and 57 in the control period. The median delirium- and coma-free days alive were 15 days [IQR 0–26] in the intervention group and 10 days [IQR 0–24] in the control group (level change −0.48 days, 95% confidence interval (95%CI) −7 to 6 days, p = 0.87; slope change −0.95 days, 95%CI −2.41 to 0.52 days, p = 0.18). Conclusions: In neurological ICU patients, our multicomponent non-pharmacological nursing intervention program did not change the number of delirium-free and coma-free days alive after 28 days. Full article

(This article belongs to the Special Issue Enhancing Recovery after Intensive Care Medicine in Clinical Practice)

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11 pages, 1180 KiB

Open AccessArticle

Total Plasma Exchange in Neuromuscular Junction Disorders—A Single-Center, Retrospective Analysis of the Efficacy, Safety and Potential Diagnostic Properties in Doubtful Diagnosis

by Andreas Totzeck, Michael Jahn, Benjamin Stolte, Andreas Thimm, Christoph Kleinschnitz and Tim Hagenacker

J. Clin. Med. 2022, 11(15), 4383; https://doi.org/10.3390/jcm11154383 - 28 Jul 2022

Cited by 2 | Viewed by 1520

Abstract

Neuromuscular junction disorders (NJDs) are a heterogeneous group of diseases including myasthenia gravis (MG). In some cases, patients are present with myasthenic symptoms without evidence of autoimmune antibodies, making diagnosis challenging. Total plasma exchange (TPE) has proven efficacy in NJDs. The objective is [...] Read more.

Neuromuscular junction disorders (NJDs) are a heterogeneous group of diseases including myasthenia gravis (MG). In some cases, patients are present with myasthenic symptoms without evidence of autoimmune antibodies, making diagnosis challenging. Total plasma exchange (TPE) has proven efficacy in NJDs. The objective is to describe the safety and efficacy of TPE in NJD patients with questionable disease activity or uncertain diagnosis in order to assess the diagnostic potential of TPE. We report an observational, retrospective cohort study of clinical routine data. All the data were derived from the electronic medical records of the Department of Neurology at University Hospital Essen. We searched for patients with NJDs between 1 July 2018 and 30 June 2021. Of the 303 patients who presented to the department with NJDs, 20 were treated with TPE; 9 patients did not show a measurable benefit from TPE (45%), 6 of whom were diagnosed with seronegative MG. Of these, 3 (50%) had long-standing ocular symptoms. There were decreases in the mean arterial pressure, hemoglobin, hematocrit and fibrinogen during treatment, which were not considered clinically relevant. In (seronegative) myasthenic patients, TPE may help to verify an uncertain diagnosis or to reveal possible muscle damage, allowing unnecessary therapy to be avoided. Full article

(This article belongs to the Special Issue Enhancing Recovery after Intensive Care Medicine in Clinical Practice)

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10 pages, 411 KiB

Open AccessArticle

A Modified Physical Disability Screening Model after Treatment in the Intensive Care Unit: A Nationwide Derivation-Validation Study

by Malihe Sadat Moayed, Amir Vahedian-Azimi, Keivan Gohari-Moghadam, Mohammad Asghari-Jafarabadi, Željko Reiner and Amirhossein Sahebkar

J. Clin. Med. 2022, 11(12), 3251; https://doi.org/10.3390/jcm11123251 - 7 Jun 2022

Cited by 1 | Viewed by 1198

Abstract

Background: Many of the survivors of critical illnesses in the intensive care unit (ICU) suffer from physical disability for months after the treatment in the ICU. Identifying patients who are susceptible to disability is essential. The purpose of the study was to modify [...] Read more.

Background: Many of the survivors of critical illnesses in the intensive care unit (ICU) suffer from physical disability for months after the treatment in the ICU. Identifying patients who are susceptible to disability is essential. The purpose of the study was to modify a model for early in-ICU prediction of the patient’s risk for physical disability two months after the treatment in the ICU. Methods: A prospective multicenter derivation–validation study was conducted from 1 July 2015, to 31 August 2016. We modified a model consisting of three risk factors in the derivation group and tested the modified model in the validation group. They were asked for their physical abilities before being admitted, two months after discharge from the ICU by a binary ADL staircases questionnaire. The univariate and multivariate logistic regression was used to modify physical disability components in the derivation data set. Receiver operating characteristic curves were used to determine the sensitivity and specificity of the threshold values in the validation group. Results: Five-hundred nineteen survivors were enrolled in the derivation group, and 271 in the validation. In multivariable analysis, the odds ratio (OR) of physical disability significantly increased with educational level ≤ elementary school (OR: 36.96, 95%CI: 18.14–75.29), inability to sit without support (OR: 15.16, 95%CI: 7.98–28.80), and having a fracture (OR: 12.74, 95%CI: 4.47–36.30). The multivariable validation model indicated that education level, inability to sit without support, and having a fracture simultaneously had sensitivity 71.3%, specificity 88.2%, LR+ 6.0, LR− 0.33, PPV 90.9, and NPV 64.9 to predict physical disability. Applying the coefficients derived from the multivariable logistic regression fitted on the derivation dataset in the validation dataset and computing diagnostic index sensitivity 100%, specificity 60.5%, LR+ 2.5, LR− 0.003, PPV 80.8, and NPV 100. The modified model had an excellent prediction ability for physical disability (AUC ± SE = 0.881 ± 0.016). Conclusions: Low education level, inability to sit without support, and having a fracture in a modified model were associated with the development of physical disability after discharge from ICU. Therefore, these clinical variables should be considered when organizing follow-up care for ICU survivors. Full article

(This article belongs to the Special Issue Enhancing Recovery after Intensive Care Medicine in Clinical Practice)

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14 pages, 2891 KiB

Open AccessArticle

Sex-Specific Aspects of Skeletal Muscle Metabolism in the Clinical Context of Intensive Care Unit-Acquired Weakness

by Lilian Jo Engelhardt, Julius J. Grunow, Tobias Wollersheim, Niklas M. Carbon, Felix Balzer, Joachim Spranger and Steffen Weber-Carstens

J. Clin. Med. 2022, 11(3), 846; https://doi.org/10.3390/jcm11030846 - 5 Feb 2022

Cited by 8 | Viewed by 2772 | Correction

Abstract

(1) Background: Female sex is considered a risk factor for Intensive Care Unit-Acquired Weakness (ICUAW). The aim is to investigate sex-specific aspects of skeletal muscle metabolism in the context of ICUAW. (2) Methods: This is a sex-specific sub-analysis from two prospectively conducted trials [...] Read more.

(1) Background: Female sex is considered a risk factor for Intensive Care Unit-Acquired Weakness (ICUAW). The aim is to investigate sex-specific aspects of skeletal muscle metabolism in the context of ICUAW. (2) Methods: This is a sex-specific sub-analysis from two prospectively conducted trials examining skeletal muscle metabolism and advanced muscle activating measures in critical illness. Muscle strength was assessed by Medical Research Council Score. The insulin sensitivity index was analyzed by hyperinsulinemic-euglycemic (HE) clamp. Muscular metabolites were studied by microdialysis. M. vastus lateralis biopsies were taken. The molecular analysis included protein degradation pathways. Morphology was assessed by myocyte cross-sectional area (MCSA). Multivariable linear regression models for the effect of sex on outcome parameters were performed. (3) Results: n = 83 (♂n = 57, 68.7%; ♀n = 26, 31.3%) ICU patients were included. ICUAW was present in 81.1%♂ and in 82.4%♀ at first awakening (p = 0.911) and in 59.5%♂ and in 70.6%♀ at ICU discharge (p = 0.432). Insulin sensitivity index was reduced more in women than in men (p = 0.026). Sex was significantly associated with insulin sensitivity index and MCSA of Type IIa fibers in the adjusted regression models. (4) Conclusion: This hypothesis-generating analysis suggests that more pronounced impairments in insulin sensitivity and lower MCSA of Type IIa fibers in critically ill women may be relevant for sex differences in ICUAW. Full article

(This article belongs to the Special Issue Enhancing Recovery after Intensive Care Medicine in Clinical Practice)

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12 pages, 743 KiB

Open AccessArticle

Outcomes in Critically Ill Patients Sedated with Intravenous Lormetazepam or Midazolam: A Retrospective Cohort Study

by Björn Weiss, David Hilfrich, Gerald Vorderwülbecke, Maria Heinrich, Julius J. Grunow, Nicolas Paul, Jochen Kruppa, Bruno Neuner, Berthold Drexler, Felix Balzer and Claudia D. Spies

J. Clin. Med. 2021, 10(18), 4091; https://doi.org/10.3390/jcm10184091 - 10 Sep 2021

Cited by 4 | Viewed by 2222

Abstract

The benzodiazepine, midazolam, is one of the most frequently used sedatives in intensive care medicine, but it has an unfavorable pharmacokinetic profile when continuously applied. As a consequence, patients are frequently prolonged and more deeply sedated than intended. Due to its distinct pharmacological [...] Read more.

The benzodiazepine, midazolam, is one of the most frequently used sedatives in intensive care medicine, but it has an unfavorable pharmacokinetic profile when continuously applied. As a consequence, patients are frequently prolonged and more deeply sedated than intended. Due to its distinct pharmacological features, including a cytochrome P450-independent metabolization, intravenous lormetazepam might be clinically advantageous compared to midazolam. In this retrospective cohort study, we compared patients who received either intravenous lormetazepam or midazolam with respect to their survival and sedation characteristics. The cohort included 3314 mechanically ventilated, critically ill patients that received one of the two drugs in a tertiary medical center in Germany between 2006 and 2018. A Cox proportional hazards model with mortality as outcome and APACHE II, age, gender, and admission mode as covariates revealed a hazard ratio of 1.75 [95% CI 1.46–2.09; p < 0.001] for in-hospital mortality associated with the use of midazolam. After additionally adjusting for sedation intensity, the HR became 1.04 [95% CI 0.83–1.31; p = 0.97]. Thus, we concluded that excessive sedation occurs more frequently in critically ill patients treated with midazolam than in patients treated with lormetazepam. These findings require further investigation in prospective trials to assess if lormetazepam, due to its ability to maintain light sedation, might be favorable over other benzodiazepines for sedation in the ICU. Full article

(This article belongs to the Special Issue Enhancing Recovery after Intensive Care Medicine in Clinical Practice)

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10 pages, 931 KiB

Open AccessArticle

Plasma Neutrophil Gelatinase-Associated Lipocalin Is Useful for Predicting Mortality in Critically Ill Patients

by Izabela Duda and Łukasz Krzych

J. Clin. Med. 2021, 10(12), 2576; https://doi.org/10.3390/jcm10122576 - 10 Jun 2021

Cited by 4 | Viewed by 1529

Abstract

Elevated neutrophil gelatinase-associated lipocalin (NGAL) occurs in a wide range of systemic diseases. This study examined the clinical utility of plasma NGAL to predict intensive care unit (ICU) and in-hospital mortality in critically ill patients. A total of 62 patients hospitalized in a [...] Read more.

Elevated neutrophil gelatinase-associated lipocalin (NGAL) occurs in a wide range of systemic diseases. This study examined the clinical utility of plasma NGAL to predict intensive care unit (ICU) and in-hospital mortality in critically ill patients. A total of 62 patients hospitalized in a mixed ICU were included; pNGAL, creatinine, and C-reactive protein (CRP) were assayed on four consecutive days (D1-D4) following ICU admission. APACHE II score (Acute Physiology and Chronic Health Evaluation) was calculated 24 h post-admission. ICU mortality reached 35% and in-hospital mortality was 39%. The median pNGAL at admission was 142.5 (65.6–298.3) ng/mL. pNGAL was significantly higher in non-survivors compared to survivors. The highest accuracy for ICU mortality prediction was achieved at the pNGAL cutoff of 93.91 ng/mL on D4 area under the curve (AUC) = 0.89; 95%CI 0.69–0.98 and for in-hospital mortality prediction was achieved at the pNGAL cutoff of 176.64 ng/mL on D3 (AUC = 0.86; 95%CI 0.69–0.96). The APACHE II score on ICU admission predicted ICU mortality with AUC = 0.89 (95%CI 0.79–0.96) and in-hospital mortality with AUC = 0.86 (95%CI 0.75–0.94). Although pNGAL on D1 poorly correlated with APACHE II (R = 0.3; p = 0.01), the combination of APACHE II and pNGAL on D1 predicted ICU mortality with AUC = 0.90 (95%CI 0.79–0.96) and in-hospital mortality with AUC = 0.95 (95%CI 0.78–0.99). Maximal CRP during study observation failed to predict ICU mortality (AUC = 0.62; 95%CI 0.49–0.74), but helped to predict in-hospital mortality (AUC = 0.67; 95%CI 0.54–0.79). Plasma NGAL with combination with the indices of critical illness is a useful biomarker for predicting mortality in heterogeneous population of ICU patients. Full article

(This article belongs to the Special Issue Enhancing Recovery after Intensive Care Medicine in Clinical Practice)

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Review

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21 pages, 1080 KiB

Open AccessReview

Perceived Severity of Stressors in the Intensive Care Unit: A Systematic Review and Semi-Quantitative Analysis of the Literature on the Perspectives of Patients, Health Care Providers and Relatives

by Henning Krampe, Claudia Denke, Jakob Gülden, Vivian-Marie Mauersberger, Lukas Ehlen, Elena Schönthaler, Maximilian Markus Wunderlich, Alawi Lütz, Felix Balzer, Björn Weiss and Claudia D. Spies

J. Clin. Med. 2021, 10(17), 3928; https://doi.org/10.3390/jcm10173928 - 31 Aug 2021

Cited by 16 | Viewed by 3143

Abstract

The aim of this study was to synthesize quantitative research that identified ranking lists of the most severe stressors of patients in the intensive care unit, as perceived by patients, relatives, and health care professionals (HCP). We conducted a systematic literature search in [...] Read more.

The aim of this study was to synthesize quantitative research that identified ranking lists of the most severe stressors of patients in the intensive care unit, as perceived by patients, relatives, and health care professionals (HCP). We conducted a systematic literature search in PubMed, MEDLINE, EMBASE, PsycInfo, CINAHL, and Cochrane Library from 1989 to 15 May 2020. Data were analyzed with descriptive and semi-quantitative methods to yield summarizing ranking lists of the most severe stressors. We synthesized the results of 42 prospective cross-sectional observational studies from different international regions. All investigations had assessed patient ratings. Thirteen studies also measured HCP ratings, and four studies included ratings of relatives. Data indicated that patients rate the severity of stressors lower than HCPs and relatives do. Out of all ranking lists, we extracted 137 stressor items that were most frequently ranked among the most severe stressors. After allocation to four domains, a group of clinical ICU experts sorted these stressors with good to excellent agreement according to their stress levels. Our results may contribute to improve HCPs’ and relatives’ understanding of patients’ perceptions of stressors in the ICU. The synthesized stressor rankings can be used for the development of new assessment instruments of stressors. Full article

(This article belongs to the Special Issue Enhancing Recovery after Intensive Care Medicine in Clinical Practice)

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