Category Archives: After-care

How do I estimate the chances of survival? State of the Art Session

 

Risk assessment: The basics

(Hannah Wunsch)

Risk models usually incorporate age, co-morbidities, diagnosis, some form of vital signs (perhaps leave out physiology for simplicity)

 

Current models balance pragmatism and need for certain data; creating a good risk assessment model is hard (include a statistician!)

 

Often missing:

  • Patient preferences for care e.g DNR, choice to withdraw
  • Physician autonomy choice to withdraw
  • Support availability upon discharge e.g. family, care system

 

Small changes to things like outcome choice can have an impact

 

External validation of severity of illness models

(Hannah Wunsch)

 

External validation is important

  • describe severity illness in quantifiable way
  • knowledge of care in a hospital / region
  • ability to compare outcomes
  • assess changes in care

 

External validation will show if model performs well in other places / datasets

  • discrimination (ability of test to correctly classify those with and without disease/outcome)
  • calibration (whether or not the observed event rates match expected event rates in subgroups of the model population)

 

Don’t blame quality of care / case mix / decision-making before investigating why external validation is not working

 

Take into account any upstream issues (unrelated to ITU care itself) causing data to ‘appear different’ from expected

e.g. delay to ITU admission might mean more / better care while pt still on ward

e.g. transfer to Long Term Acute Care hospital for pt to die (hospital mortality rate looks better)

 

Consider Recalibration, and ask Why recalibration is needed… but sometimes a model truly isn’t good enough to use

 

 

Predicting Quality of Life in survivors

(Philipp Metnitz)

 

Focus on health aspects – function and feelings / wellbeing

 

>200 articles and >200 instruments published: numerous unique instruments available

– 29% articles used Baseline assessment of QOL

– 63% articles used Short Form-36; 19% used EQ-5D-3L

 

Short Form-36: patient-reported, 36 item survey covering physical / emotional / social functioning, mental health, pain, health perceptions

 

EQ-5D: health state description (mobility, self care, usual activities, pain, anxiety/depression) and evaluation using VAS

 

Physical QOL impacts on return to work, carer burden, cost to care system

 

Physicians tend to be over-optimistic in predicting QOL with approx. 30% error

IMG_0230

 

Long term cognitive impairment in ICU survivors

(Arjen Slooter)

 

Cognitive impairment after intensive care unit admission: a systematic review. (Wolters et al., Intensive Care Med 2013; 39:376-86)

  • 19 studies
  • heterogeneous population (elderly, ARDS, sepsis)
  • duration of follow up 2months – 13 yrs)
  • variation in tests applied
  • limitations – no premorbid baseline, no correction for educational level

 

Cognitive impairment frequent (11-62%)

  • impairment depends on Pre-admission function
  • duration of delirium related to cognitive impairment

 

Mechanisms in sepsis:

  • neuroinflammation (this persists in the older brain where microglia are pre-primed)
  • microcirculatory changes, hypotension, microthromboses/haemorrhages, endothelial dysfunction
  • increased NO activity
  • viral reactivation through immunosuppression (CMV / HSV)

 

Assessment currently:

  • Neuropsychological test with neuropsychologist in clinical setting (artificial situation)
  • Cognitive complaints (subjective based on emotional state, may not relate to ADL impairment ß most important aspect!)

 

Future assessment:

  • Functional testing e.g. shopping in supermarket using Virtual Reality (requires language, attention, memory, executive function)
  • VR can also be applied to training in tasks à directly relevant to patient’s ADLs

 

 

Predicting outcome one week after admission

(Dylan W. de Lange)

 

Assessing severity of illness with scoring systems: is the trend of repeated scores over time more relevant than the magnitude of a single score?

 

Designing a model for ICU pts staying > 7 days to predict 1-year mortality and QOL (EuroQOL-5D form to pts post-discharge)

 

Simple (can be used bedside) vs Detailed model: helps ‘gut feeling’ about pt for shared decision making with pt and family (but not very helpful for individual prognostication)

IMG_0263

IMG_0265

 

The PARTNER trial

The PARTNER trial was presented today (published over the summer in NEJM) which is the latest in the critical care community’s attempt to support families with loved ones in ICU.

We know that its a stressful time for families (and of course patients) and we think we could do better in communication with them, and support.

The family members who are involved in the discussion around care and end of life and limitation of treatment often suffer psychological morbidity

Could these outcomes for families be improved by “reengineering” the ICU team and up-skilling them? And interestingly, might that even extend to less burden of treatment for patients?

Thats what the partner trial set out to discover and Derek Angus presented the results this morning in Paris

At its heart PARTNER was a nurse driven emotional support and relationship building intervention

The key thrust of the intervention was around 3 things

  1. Protocolled pathway of family support
  2. Advanced communication skills training for staff
  3. Intensive implementation support of the pathway

It was a stepped wedge cluster RCT in 5 different ICUs  of differing sizes and case mix.

It didn’t show a difference in its primary outcome (HADS score) but it did improve how people felt – families AND nurses! Which is promising – but the real win was reduced length of stay for me, a relatively cheap intervention that saves money, sounds good huh!

Of note there was an apparent increase in ICU mortality, as some patients had treatment limited earlier – but that disappeared at later follow up.

If you are interested in the field its worth reading this study from Curtis et al which was similar but did show a difference in depressive symptoms in families later on… Why? not sure – perhaps just the play of chance??? Perhaps difference in the way the intervention was blanket applied?

Your roving reporter, JS

Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France

Hot Topics Session

It is well recognised that critically ill elderly patient have a higher mortality and therefore the beneficial effect of intensive care unit (ICU) admission variable ICU use among this population have let to significant difference in uptake.

Guidet and colleagues performed a cluster, randomised trial of admission versus standard care in 3036 elderly patients aged 75 years and above. In their multicentre randomised trail, suitable patients were allocated to routine or non-routine admission as per the following:

CONSORT Diagram

Outcome Measures

  • Primarily 6 months
  • Secondarily ICU admission rate, in-hospital death, functional status and quality of life.

 

Results

Results

 

  • Disappointingly there was no difference seen in any of the outcome measures, even after adjustment for differences in illness severity and patients admitted to ICU had an INCREASED risk of death at six months despite an increase ICU admission rates.
  • Functional status and physical quality of life at six months did not differ significantly.

 

What does this mean?

  • As our ICU population changes it may be that a systematic approach which admits all elderly patients has no effect upon outcome.
  • Further international trials are needed before we know whether this is applicable to other populations.

Clinical Trial Session 2

CAESAR Study (Azoulay)

Post-ICU syndrome and the burden of care on relatives. Hence the need to develop a tool to assess this.

A high CAESAR score represents higher family satisfaction with care

Conclusion – CAESAR instrument

  • new instrument based on family experience that will help develop family centred care
  • lower scores associated with higher burden
  • clinically, may be useful to identify vulnerable families

 

FLUID-TRIPS (Hammond)

Albumin studies – SAFE, VISEP, CRYSTMAS, CHEST, 6S, ALBIOS

Inter-country variation in types of fluid prescribed

Conclusion

  • signification variation in fluid use remains
  • significant secular changes in patterns of fluid resuscitation between 2007-2014
  • crytalloids still predominate
  • increased use of balanced salt solutions
  • pattern of colloid use consistent with recent RCT

SAFE TRIP study

Fluid-TRIPS protocol

 

CHECKLIST-ICU (Cavalanti)

Checklist and daily goals read out during round

No difference in mortality!

CHECKLIST ICU Trial protocol

Trial statistical analysis plan

Protocols and Hospital Mortality in Critically Ill Patients: The United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study

 

Very high volume hemofiltration with the Cascade system in septic shock patients

Cascade trial