Blood transfusion in critical care

Blood transfusion is frequent in critical care. Transfusion raises the mass of transfused blood components and is lifesaving in acute hemorrhage. In massive transfusion (>10 units of red blood cells), early attempts to restore coagulation function appear helpful. Transfusion in non-bleeding patients is largely prophylactic, is seldom evidence-based, and may be deleterious. In hemodynamically stable critical care patients, level I evidence suggests that a hemoglobin of >7 g/dL and platelet counts of >10,000/μL are well tolerated

Optimizing Critical Illness Recovery: Perspectives and Solutions from the Caregivers of ICU Survivors

Objectives: To understand the unmet needs of caregivers of ICU survivors, how they accessed support post ICU, and the key components of beneficial ICU recovery support systems as identified from a caregiver perspective. Design: International, qualitative study. Subjects: We conducted 20 semistructured interviews with a diverse group of caregivers in the United States, the United Kingdom, and Australia, 11 of whom had interacted with an ICU recovery program. Setting: Seven hospitals in the United States, United Kingdom, and Australia. Interventions: None. Measurements and Main Results: Content analysis was used to explore prevalent themes related to unmet needs, as well as perceived strategies to improve ICU outcomes. Post-ICU care was perceived to be generally inadequate. Desired caregiver support fell into two main categories: practical support and emotional support. Successful care delivery initiatives included structured programs, such as post discharge telephone calls, home health programs, post-ICU clinics, and peer support groups, and standing information resources, such as written educational materials and online resources. Conclusions: This qualitative, multicenter, international study of caregivers of critical illness survivors identified consistently unmet needs, means by which caregivers accessed support post ICU, and several care mechanisms identified by caregivers as supporting optimal ICU recovery

Key mechanisms by which post-ICU activities can improve in-ICU care: results of the international THRIVE collaboratives

Objective: To identify the key mechanisms that clinicians perceive improve care in the intensive care unit (ICU), as a result of their involvement in post-ICU programs. Methods: Qualitative inquiry via focus groups and interviews with members of the Society of Critical Care Medicine’s THRIVE collaborative sites (follow-up clinics and peer support). Framework analysis was used to synthesize and interpret the data. Results: Five key mechanisms were identified as drivers of improvement back into the ICU: (1) identifying otherwise unseen targets for ICU quality improvement or education programs—new ideas for quality improvement were generated and greater attention paid to detail in clinical care. (2) Creating a new role for survivors in the ICU—former patients and family members adopted an advocacy or peer volunteer role. (3) Inviting critical care providers to the post-ICU program to educate, sensitize, and motivate them—clinician peers and trainees were invited to attend as a helpful learning strategy to gain insights into post-ICU care requirements. (4) Changing clinician’s own understanding of patient experience—there appeared to be a direct individual benefit from working in post-ICU programs. (5) Improving morale and meaningfulness of ICU work—this was achieved by closing the feedback loop to ICU clinicians regarding patient and family outcomes. Conclusions: The follow-up of patients and families in post-ICU care settings is perceived to improve care within the ICU via five key mechanisms. Further research is required in this novel area

Enablers and Barriers to Implementing ICU Follow-Up Clinics and Peer Support Groups Following Critical Illness: The Thrive Collaboratives

OBJECTIVES: Data are lacking regarding implementation of novel strategies such as follow-up clinics and peer support groups, to reduce the burden of postintensive care syndrome. We sought to discover enablers that helped hospital-based clinicians establish post-ICU clinics and peer support programs, and identify barriers that challenged them. DESIGN: Qualitative inquiry. The Consolidated Framework for Implementation Research was used to organize and analyze data. SETTING: Two learning collaboratives (ICU follow-up clinics and peer support groups), representing 21 sites, across three continents. SUBJECTS: Clinicians from 21 sites. MEASUREMENT AND MAIN RESULTS: Ten enablers and nine barriers to implementation of "ICU follow-up clinics" were described. A key enabler to generate support for clinics was providing insight into the human experience of survivorship, to obtain interest from hospital administrators. Significant barriers included patient and family lack of access to clinics and clinic funding. Nine enablers and five barriers to the implementation of "peer support groups" were identified. Key enablers included developing infrastructure to support successful operationalization of this complex intervention, flexibility about when peer support should be offered, belonging to the international learning collaborative. Significant barriers related to limited attendance by patients and families due to challenges in creating awareness, and uncertainty about who might be appropriate to attend and target in advertising. CONCLUSIONS: Several enablers and barriers to implementing ICU follow-up clinics and peer support groups should be taken into account and leveraged to improve ICU recovery. Among the most important enablers are motivated clinician leaders who persist to find a path forward despite obstacles

The Burdens of Survivorship: An Approach to Thinking about Long-Term Outcomes after Critical Illness.

Internationally accepted approaches to the study of functioning and disability can inform critical care practitioners and scholars in their study of functional limitations, disability, and quality of life after critical illness and intensive care. Therefore this article provides an introduction to the World Health Organization's International Classification of Functioning, Disability and Health (ICF). The Institute of Medicine has also recommended this approach for the study of disability. This conceptual framework divides potential problems as follows: problems in body structure and tissue, limitations in activity (i.e., functional limitations as assessed in standardized environments), and restrictions in participation (i.e., the inability to fulfill a social role). The ICF draws attention to effect modifiers that can prevent problems at one level from progressing (or conversely can hasten their progression) to profound decrements in a patient's quality of life. It is particularly relevant for studies of long-term outcomes after critical illness and post-intensive care syndrome (PICS). This article provides a discussion of the ICF specific to the intensive care unit and the disablement process, with particular attention to new opportunities for intervention and their implications for cost and quality of life.This work was supported by NIH grants K08 HL091249 (TJI) and K12RR023250 (GN), as well as the Society of Critical Care Medicine’s 2010 Vision Grant and the Claude D. Pepper Older Americans Independence Center at the University of Maryland (P30-AG028747).Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/93630/1/12.I.Netzer.Sem.Resp.Crit.Care.Burdens.of.Survivorship.pd

Injured patients with very high blood alcohol concentrations

Objective—Most data regarding high blood alcohol concentrations (BAC) ≥400 mg/dL have been from alcohol poisoning deaths. Few studies have described this group and reported their alcohol consumption patterns or outcomes compared to other trauma patients. We hypothesized trauma patients with very high BACs arrived to the trauma center with less severe injuries than their sober counterparts. Method—Historical cohort of 46,222 patients admitted to a major trauma center between January 1, 2002 and October 31, 2011. BAC was categorized into ordinal groups by 100 mg/dL intervals. Alcohol questionnaire data on frequency and quantity was captured in the BAC ≥400 mg/dL group. The primary analysis was for BAC ≥400 mg/dL. Results—BAC was recorded in 44,502 (96.3%) patients. Those with a BAC ≥400 mg/dL accounted for 1.1% (147) of BAC positive cases. These patients had the lowest proportion of severe trauma and in-hospital death in comparison with the other alcohol groups (p\u3c0.001), and the group comprised mainly of falls. Admission Glasgow Coma Scale was a poor predictor for traumatic brain injury in the high BAC group. Readmission occurred in 22.4% (33) of patients the BAC ≥400 group. The majority of these patients reported drinking alcohol four or more days per week (81, 67.5%) and five or more drinks per day (79, 65.8%), evident of risky alcohol use. Conclusions—Most traumas admitted with BAC ≥400 mg/dL survived and their injuries were less severe than their less intoxicated and sober counterparts. They also had evidence for risky alcohol use and nearly one-quarter returned to the trauma center with another injury over the study period. Recognition of t