Nursing & Allied Health Professionals – Post ICU Care: Impact & consequences (Abstracts)

Dealing with the aftermath of critical illness – the ENSURE (ENabling and SUpporting REcovery) intensive care follow up clinic

(Andrew Lockwood)

ICU survivors face long journey beyond hospital discharge

Adoption of InS:PIRE (Glasgow) post-ICU rehab model, incorporating needs of patient and family

  • Included: age >18, ICU stay >4d, self-referral or GP referral, pts from other ICUs living in catchment area
  • Engage primary care team (GPs on average see 1 ICU survivor per year)

 

5 week MDT approach

  • Off site location: parking, refreshments, no associations with hospital
  • checklist for concerns sent prior to identify issues and identify best MDT member to handle
  • weekly session for pt, also Carer session away from ICU survivor
  • Key strength: pt volunteers (previous ICU survivors)
  • Consultant and Psychologist meet with pt 2 out of 5 weeks to cover complex medical and psychological needs

Of note:

  1. Outcome measure score (including personal health rating, control of life etc) to ensure this follow up is adding value –> No drop-off in the score up to 1 year after the first follow-up meeting
  2. Follow-up team able to make direct onward referrals for further specialist input without going via GP
  3. Anecdotal report of pt benefiting greatly from visiting ICU bedspace – nightmares and flashbacks dissipated quickly after this
  4. Important to realise that ICU pts who were not sedated / ventilated can still develop psychological challenges during recovery
  5. Major stressor found not to be ICU admission but ICU discharge to ward –> will lead on to develop study morning for ward staff regarding post-ICU care
  6. Quarterly newsletter for ICU staff to feedback learning points, verbal messages passed to any named ward staff
  7. Noise issue – Noise Ears now installed to monitor and analyse noise levels, address accordingly
  8. Pt diaries previously for long-stayers, but all pts can benefit from diary
  9. Carer session – Carer Strain Index done on first meeting, but limited intervention as carer is not the pt

 

How does healthcare quality influence Care Left Undone in neonatal and paediatric intensive care units?

(Silvia Rossi)

Care Left Undone (CLU) phenomenon gained interest within the past decade – understanding this can contribute to quality improvement

Aim: Investigate which nursing staff and work environment variables could influence the prevalence of CLU in NICUs and PICUs

13 Hospitals: 3 Paediatric free-standing hospitals, 10 General hospitals, 169 Units

13 types of CLU (activity omitted on the nurse’s most recent shift)

Variables considered: Work environment (PES-NWI), Depersonalisation (MBI), Emotional exhaustion (MBI), Intention-to-leave, Quality of Healthcare

6 categories of care activities most at risk of becoming CLU:

  • adequate pt surveillance
  • pain management
  • educating pt and family
  • adequately documenting nursing care
  • planning care
  • frequent changing of pt position

 

Variables that could Increase the risk of omission:

  • Depersonalisation — Oral hygiene (OR=1.065; 95%CI=1.012-1.120)
  • Emotional exhaustion — Develop or update nursing care plans (OR=1.029; 95%CI=1.009-1.050)
  • Intention to leave job (within 1 year) — Prepare pts and families for discharge (OR=1.983, 95%CI=1.243-3.164)

Variables that could Reduce the risk of omission:

  • Good work environment — Develop or update nursing care plans (OR=0.152; 95%CI=0.342-0.768)

NOT taken into account: nursing workload, severity of illness, nurse-pt ratio

Conclusion:

Nurses miss some activities in presence of personal conditions and Environmental conditions including Organisational culture and Unit behaviour

Need to consider the CLU phenomenon in its Entirety

 

Effect of nurse led follow-up consultations to improve Sense of Coherence in patients discharged after intensive care treatment

(Ase Valso)

Pts with delusional and frightening ICU memories have increased risk for Post-traumatic stress (PTS) symptoms –> Constructing an illness narrative to make sense of ICU experiences important for psychological recovery

Sense of Coherence (SOC) reflects ability to cope with stress

  • Comprehensibility: make sense of adversity
  • Manageability: resources to meet challenges
  • Meaningfulness: challenges worth engagement

Included: >18 yo, ICU stay >24hrs

PTS score done shortly post-d/c from ICU – pts with higher scores (>25) randomised:

Standard care (control) or

Nurse-led follow up consultation (Intervention)

  • 1 meeting shortly after d/c (45-60mins), 1 or 2 further meetings (phone or in-person on ward)
  • Structured guide based on trauma focused CBT – aiming to give patient an improved Sense of Coherence, not psychological therapy (intervention nurse is experienced and familiar with ICU care, given 2d training but not experienced in psychology or psychiatry)

Of note:

  1. pts in intervention group scored highly in the SOC score, and nurse-led intervention did not significantly increase SOC compared to control group
  2. No obvious difference in outcome whether follow up was done by phone or in-person
  3. Criticism by author : existing belief is that early intervention to restore SOC may prevent onset of post-traumatic stress, but this study may have been carried out too early with sick patients; duration of intervention period may have been too short to detect any difference

 

Pain occurrence and associated factors after discharge from the intensive care unit to the hospital ward

(Kirsti Toien)

Same pt cohort as prevented in previous abstract on SOC and Nurse-led intervention

Pain is a serious and challenging problem for ICU pts, impacting on respiration, mobilisation and rehabilitation

  • pain management is important part of ICU care
  • focus and research is lacking on pain-related issues post-ICU discharge

 

Aim: To investigate pain intensity and interference with daily activity in pts immediately after ICU discharge, and to explore possible variables associated with worst pain and pain interference among demographic and clinical variables

Results (pain location) n=469

Abdomen  202 (43%); Lower back 132 (28%); Shoulder / forearm 102 (22%); Chest 82 (18%); Neck 76 (16%); Pelvis 71 (15%); Knee 70 (15%)

 

Physical and Psychological Outcomes of patients discharged from a rehab-active Critical Care Unit in the United Kingdom

(Fiona Howroyd)

Post-intensive Care syndrome (PICS):

  • physical (e.g. weakness, pain)
  • functional
  • psychosocial (e.g. anxiety, depression)
  • cognitive (memory impairment)

Aim: To identify levels of anxiety, depression, psychological stress and mobility, and to explore the impact of mobility levels upon psychological outcomes

Data collection over 3 months

Outcomes:

  • Hospital Anxiety Depression Scale (HADS)
  • Intensive Care Psychological Assessment Tool e.g. hallucinations, flashbacks, sleep problems (IPAT)
  • Manchester Mobility Scale (MMS)

Conclusions:

  1. High prevalence of psychological morbidity
  2. Increased mobility associated with less anxiety
  3. Increased mobility associated with shorter length of stay on ward

Of note: Structured ward follow up including physiotherapist, nurse and psychological support

Mobile pts can still have PICS and should be supported as required

Proteins – Is more better for all?

Enteral or Parenteral – Any difference?

(Olav Rooyackers)

Clear ESPEN recommendations: Normal way of eating is best = Oral > EN > PN

If EN / PN done well, with equal calories delivered — NO significant difference in outcomes of mortality 

Small RCT by Ferrie et al: PN with higher levels of amino acids (1.2g/kg) give small improvements in different measures e.g. grip strength, muscle thickness compared to PN with lower levels of amino acids (0.8g/kg)

FEED trial: to compare effect of standard EN formula vs. EN formula with higher protein supplementation on muscle mass and strength amongst other outcomes

Both EN and PN protein supplementation likely to affect muscle in some way.

  • currently no direct comparison between EN and PN in ICU pts
  • EN protein is partly taken up by the gut; PN protein bypasses splanchnic circulation – does this feed muscles directly and is it better??
  • Liebau et al. Critically ill pts handle protein differently – the critically ill gut is ‘selfish’ and extracts more amino acids compared to the gut in healthy volunteers, though initiation of EN causes a small but detectable improvement in whole body protein balance

Small study in 14 elderly pts comparing EN and PN amino acids administration showed muscle protein synthesis was not affected by route of administration

  • note: high doses amino acids used, unclear if a difference in muscle protein synthesis stimulation would be seen at lower doses of EN and PN administration

 

Relation between protein intakes and frailty

(Zudin A. Puthucheary)

Frailty is a complex interplay of factors: age, comorbidity, socio-economic status

Early days of critical illness: Immobility + Illness –> muscle protein synthesis (MPS) is decreased

Ageing population – increased age of pts admitted to ICU

  • MPS rate is similar in young and old men- however the MPS RESPONSE to exercise differs with age
  • Following resistance exercise in younger men, there is faster increase in MPS, with longer duration of persistent MPS compared to older men

 

Comorbidities contribute to Frailty: most studies performed in COPD pts

 

  • By day 9 of critical illness, Age and Premorbid health become more important in determining outcome

Socio-economic status is NOT corrected for in any trials for Nutrition

  • related to disparity in nutrition
  • significant contributor to frailty
  • pts below poverty threshold unlikely to have balanced diet
  • elderly males more likely to have energy dense meals (high CHO, low protein)

 

Functional assessment in 12 questions on social history

Note: pts usually not asked about shopping, finances, meal prep but these relate to ‘nutritional disability’!

 

Should protein and energy goals be separated?

(Jan Wernerman)

Short answer: Yes, but it’s complicated

No RCTs, only circumstantial evidence

 

How much room do we have for nutritional volume without causing overload?

  • many commercial formulae available, commonly 25kcal/gram protein

  • for most pts admitted >1 week, needing >2500kcal, a uniform algorithm can be used
  • for outliers (length of admission, body weight, energy expenditure) consider the patient separately with individualised feeding prescription

 

No hard evidence that protein under- or over-feeding do harm on short and medium term basis (very little long term data)

Avoid deliberate excessive protein feeding especially in malnourished pts as they have been protein-deficient for long time and may be at greater risk of harm from protein-overfeeding

Observational data in critically ill pts: more protein feeding appears to improve survival

Monitoring protein feeding:

  • Use nutrition chart and serum urea
  • imaging muscle mass with ultrasound or CT are technically difficult to interpret due to fluctuations in muscle water content

 

 

Care After Cardiac Arrest

TTM: where are we now?

Presentation by Lars W. Andersen

  • 26 RCTs from 2002 to 2019 + TTM2 ongoing and HYPERION trial to be released soon
  • Following 2 RCTs in 2002 (Bernard et al + HACA) the use of TTM T32-34C became widespread
  • Improves neurologically intact survival but the mechanism is uncertain
  • T36C became widely used after TTM trial (Nielsen et al, 2013) found no difference T33C vs. T36C
  • Controversies/uncertainties regarding patient selection, target temperature, timing of initiation, duration, and method

Coronary angiography: to whom and when?

Presentation by Kjetil Sunde

  • Ischemic heart disease is the most common cause of OHCA
  • STEMI: immediate coronary angiography
  • Without STEMI: ER “pit-stop” for a fast diagnostic workup (history, TTE/TEE, CT scan, lab tests)
  • PRO: diagnosis, early PCI reduces infarct size, heamodynamic stabilization, improves LVEF, TTM during PCI
  • CON: overlook other causes, heparin, delayed TTM, lot of multidisciplinary resources, infrastructure, logistics needed

Heamodynamic management

Presentation by Markus Skrifvars

  • Anoxic brain injury impairs brain perfusion autoregulation
  • Targeting MAP > 70 mmHg
  • Lower HR = better neuro outcomes
  • Focus on CO and lactate
  • “Physiologic”: MAP>70mmHg, bradycardic, moderate vasopressors, urinary output >0.5 ml/kg, lactate < 2 mmol/l after 12h, low/normal CI, normal SvO2, complete/adequate reperfusion
  • “Phatologic”: MAP<60mmHg, high vasopressors, urinary output <0.5 ml/kg, lactate>3-4mmol/l after 12h, recurrent CA, tachycardia/rapid AF, low CI/SvO2, consider IABP/ECMO.

We need to monitor what and how?

Presentation by Claudio Sandroni

  • rapidly detect ABCD abnormalities and trigger adequate responses
  • A+B: mantain normoxia/normocarbia
  • C: be aware of post-resuscitation myocardial dysfunction and sepsis-like syndrome,
    • monitor: ECG, arterial line, lactate using ABG, CO, fluid responsiveness
  • D: EEG for prognostication/seizure detection, benefit of aggressive antiepilectic treatment??
    • monitor: body T, motor response, brainstem reflexes, pupillometry, seizures, rSO2??

Patient outcome related to multi-organ failure

Presentation by Sharon Einav

  • Organ dysfunction is common after cardiac arrest and associated with worse outcome
  • Full spectrum of multiple organ failure (heart, kidney, liver, brain) must be considered to reduce morbidity, increase survival and optimize the use of healthcare resources
  • End-of-life care must be considered: withholding/withdrawing all invasive and supportive care as a collegial process between team and family

Is there a place for Vitamin C?

Presentation by Angelique Spoelstra-de Man

  • Vitamin C is the primary antioxidant
  • Ischemia and reperfusion injury causes damage to the hearth and brain increasing mortality
  • After CA plasma levels of Vitamin C are low reducing protection against oxidative stress (massive consumption?)
  • In preclinical studies vitamin C decreased myocardial damage, improved survival/neuro outcome
  • Vitamin C in Post-cardiac Arrest (VITaCCA) RCT will determine if early high doses of vitamin C improve organ function after cardiac arrest. ClinicalTrials.gov Identifier: NCT03509662

Infographic

Infographic on the topic by Tommaso Scquizzato @tscquizzato

 

Immunotherapies for cancer in the ICU

The first lecture of the day was given by the expert in the area Elie Azoulay.  He talked through immune therapies that are being used in cancer.

Immune therapy “boosts” the immune system and restores its ability to eradicate cancer cells.  There are loads of different types of immune therapy – but Azoulay focussed on the ones that are of relevance to intensivists – Adoptive Cell Transfer, encapsulating “CAR T-cells” and “checkpoint inhibitors”.

Cancer cells normally find ways to act on checkpoints (molecules on T Cells) to avoid being attacked by the immune system.  Checkpoint inhibitors, drugs like pembrolizumab and vivolumab [act on PD-1] or atezolizumab [acts on PD-L1] activate the immune system to get to work on tumours.  BUT the usual safeguards against autoimmunity within the body are also affected.  Other drugs that target CTLA-4 (such as ipilimumab used in melanoma)  act as a type of “off switch” on T Cells.  And they work in solid organ tumours – particularly in combination the oncology trial results are impressive… This paper is an overview of the field from a couple of years ago as quoted below:

There are lots of these drugs – how might you identify if your patient has received one? Well hopefully it will be abundantly clear from their treatment or oncologist – but they are all monclonal antibodies of course so end in -mab.  Heres a list:

The other type of treatment in this category then is Chimeric Antigen Receptor T Cells (CAR-T cells).  These are the patient’s own T Cells, apheresed, stimulated and expanded and then re-infused.

The treatments and trials of note are Tisagenlecuecel in the ELIANA trial for young people with refectory B Cell ALL and JULIET trial for high grade B Cell lymphoma and Axicabtagene cioleucel for relapsed B Cell lymphoma in the ZUMA-I trial.

The reason these second or third line cancer treatment matters for intensive care though is because of the serious adverse event rate.  All this immune system jiggery pokery comes at the cost of upsetting normal function and some 30 to 40% of patients will get some sort of complication:

So what will we need to do on ICU?

The lists of critical care support is quite long as theses patients can get multi organ failure requiring support! They range from ruling out infection (e.g. LP in neurotoxicity – is it CAR-T related or CNS infection/sepsis?) and admiting for close observation/monitoring, good symptom control/IV fluids through to oxygenation and ventilation for acute respiratory failure, vasopressors and shock treatment and even renal and cardiac support and monitoring.  There are specific treatments – steroids are the mainstay but blocking the cytokines responsible for the cytokine storm (for example with IL6 antagonists /  tacilizumab) and other rescue strategies.

Some of the complications are still not fully understood – for example neurotoxicity might be related to the parenchyma effect of CAR-T cells or might be a break down of the blood brain barrier, and earlier onset cytokine storm seems to lead to worse neurotoxicity – prompting some people to think there is a link.  But its still an area of research…

The current reality in many units is that CART therapy is bringing patients to ICU for reversible pathology, and because CAR T therapy is an exciting area, perhaps perhaps it will expand beyond its current remit in cancer to other conditions… So we need to be ready!

My favourite bit of Azoulays talk today was his patient information leaflet – enjoy!

Jamie