The effect of penetrating trunk trauma and mechanical ventilation on the recovery of adult survivors after hospital discharge

ABSTRACT South Africa has a high incidence of violence and death due to unnatural causes. Gunshot and/or multiple stab wounds to the trunk are consequently injuries commonly seen in South African hospitals. Penetrating injuries often necessitate explorative surgical intervention to identify and treat injuries to the internal organs. Patients are managed in the intensive care unit and frequently return to theatre for abdominal lavage prior to eventual wound closure. Critical illness with prolonged mechanical ventilation and immobilization results in some degree of muscle dysfunction. Survivors of critical illness suffer from poor functional capabilities and decreased quality of life. No formal rehabilitation programmes exist in South Africa for these patients following discharge. Purpose: To determine if patients that survived penetrating trunk trauma recover adequately spontaneously following critical illness over the first six months following discharge from the hospital. Methods: A prospective, observational study was conducted. Patients with penetrating trunk trauma were recruited from four intensive care units in Johannesburg. Patients who received mechanical ventilation < 5 days were placed in Group 1 and those who received mechanical ventilation 5 days were placed in Group 2. Lung function tests, dynamometry, quality of life, six-minute walk distance and oxygen uptake tests were performed over six months following discharge from the hospital. The obtained results for dynamometry, exercise capacity and quality of life were compared between groups and to that measured for a healthy (age and sex-matched) control group. Results and Discussion: No pulmonary function abnormalities were detected for subjects in Groups 1 or 2. Distance walked during 6MWD test was significantly reduced for subjects in Group 2 compared to the control group [one-month (p = 0.00), three-months (p = 0.00)]. Morbidity correlated significantly with distance walked by subjects in Group 2 during 6MWD test [three-months (p = 0.03), six-months (p = 0.02)]. No statistically significant differences were found between subjects during the VO2peak test although subjects in Group 1 performed better clinically than those in Group 2. At one-month there was a significant reduction in upper and lower limb strength for subjects in Group 2 compared to those in Group 1 and the controls (p = 0.00 – 0.04). Similar results were detected at the three- and six-month assessments. ICU and hospital length of stay did demonstrate a significant relationship with muscle strength at one and three months following discharge for subjects in Group 2. Severity of illness and morbidity in ICU did not have a significant relation to muscle strength for subjects in Groups 1 or 2 at any of the assessments. Subjects in Group 1 had a significant reduction in right deltoid and triceps strength compared to the controls at one-month (p = 0.00 respectively) only. No significant differences in upper and lower limb muscle strength were detected between the control group and subjects in Group 1 three and six months after discharge. Subjects in both groups had similar limitations in physical and mental aspects of quality of life one-month after discharge. Subjects in Group 1 reported a quality of life comparable to the control group by three-months. Subjects in Group 2 had significant limitations in the physical components of quality of life at three- and six-months compared to those in Group 1 and the controls [p = 0.00 – 0.02]. Conclusion: Subjects in Group 1 recovered adequately on their own within three months after discharge from hospital with regard to muscle strength, exercise capacity and all aspects of quality of life. Subjects in Group 2 presented with significant limitations in exercise capacity, muscle strength and the physical aspects of quality of life even at six months after discharge. Impaired function was related to the duration of critical illness and immobility. A physiotherapist-led rehabilitation programme may be indicated for survivors of penetrating trunk trauma that received prolonged mechanical ventilation to address cardiovascular endurance and peripheral muscle strength retraining between one and three months after discharge to address the physical disabilities observed in these subjects

The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients : synthesis of evidence and expert opinion and its translation into practice

The original publication is available at http://cre.sagepub.com/content/early/2011/04/15/0269215510397677Includes bibliographyObjective: To facilitate knowledge synthesis and implementation of evidence supporting early physical activity and mobilization of adult patients in the intensive care unit and its translation into practice, we developed an evidence-based clinical management algorithm. Methods: Twenty-eight draft algorithm statements extracted from the extant literature by the primary research team were verified and rated by scientist clinicians (n¼7) in an electronic three round Delphi process. Algorithm statements which reached a priori defined consensus – semi-interquartile range <0.5 – were collated into the algorithm. Results: The draft algorithm statements were edited and six additional statements were formulated. The 34 statements related to assessment and treatment were grouped into three categories. Category A included statements for unconscious critically ill patients; Category B included statements for stable and cooperative critically ill patients, and Category C included statements related to stable patients with prolonged critical illness. While panellists reached consensus on the ratings of 94% (32/34) of the algorithm statements, only 50% (17/34) of the statements were rated essential.Medical Research Council of South AfricaPost-prin

Changes in biopsychosocial outcomes for a mixed cohort of ICU survivors

Background: Prolonged inflammation and infection associated with being critically ill and the ensuing physical inactivity has proven negative effects on the recovery of physical function, psychological health and reintegration into society for intensive care unit (ICU) survivors. Limited evidence is available on changes in biopsychosocial outcomes for South Africans recovering from an episode of critical illness. Objectives: To determine changes in biopsychosocial outcomes for a mixed cohort of ICU survivors in hospital and at 1 month and 6 months after discharge. Method: A prospective, observational, longitudinal study was conducted. Severity of illness, mechanical ventilation (MV) duration and ICU and hospital length of stay (LOS) were recorded. Physical function in ICU test-scored (PFIT-s) was performed at discharge from ICU and hospital. At 1 month and 6 months, peripheral muscle strength, exercise endurance, health-related quality of life (HRQOL), depression status and return to work were assessed. Descriptive and inferential statistics were used. Results: Participants (n = 24) had a median age of 51.5 years, majority were male (n = 19; 79%) and most were employed before admission (n = 20; 83%). At 6 months, 11 participants (n = 11) were part of the final sample. Median PFIT-s changed significantly (0.3 points; p = 0.02) between ICU and hospital discharge. Peripheral muscle strength improved significantly for upper and lower limbs over 6 months (p = 0.00–0.03) but change in median 6-minute walk test distance (65m) was not significantly different. Significant improvements occurred in mean Medical Outcomes Short Form-36 (SF-36) physical health component scores (8.8 ± 7.6; p = 0.00). Mean SF-36 mental health component scores had a strong negative relationship with MV duration (r = −0.7; p = 0.01), LOS (r = −0.56; p = 0.04) and Patient Health Questionnaire 9 scores (r = −0.72; p = 0.01). Six participants (55%) returned to employment. Conclusion: Clinically important improvements in biopsychosocial outcomes related to physical function and social factors were observed. Limitations in mental aspects of HRQOL were present at 6 months and some reported mild depressive symptoms. Clinical implications: Intensive care unit survivors with a history of prolonged MV duration and hospital LOS who exhibit limitations in mental HRQOL, and signs of depressive symptoms should be referred to a psychologist for evaluation

Physiotherapy practice in South African intensive care units

Background. Physiotherapists are integral members of the interprofessional team that provides care and rehabilitation for patients in intensivecare units (ICUs).Objectives. To describe the current practice of physiotherapists in ICUs, determine if physiotherapists’ practice has changed since a previousreport and determine if practice is evidence based.Methodology. A questionnaire was content validated and made available electronically and in hard copy. Physiotherapists who work in ICUs inpublic or private sector hospitals or who are members of the South African Society of Physiotherapy were identified and invited to participate.Results. Survey response rate was 33.9%. Patient assessment techniques performed ‘very often’ included ICU chart assessment (n=90, 83.3%),chest auscultation (n=94, 81.8%) and cough effort (n=81, 75%). Treatment techniques performed ‘very often’ included manual chest clearance(n=101, 93.5%), in-bed mobilisation and positioning (n=91, 84.3%; n=91, 84.3%, respectively), airway suctioning (n=89, 82.4%), out-of-bedmobilisation (n=84, 77.8%), deep breathing exercises (n=83, 76.9%) and peripheral muscle-strengthening exercises (n=72, 73.1%). Morerespondents used intermittent positive pressure breathing (57 v. 28%, p=0.00), used adjustment of mechanical ventilation (MV) settings (30v. 15%, p=0.01), were involved with weaning patients from MV (42 v. 19%, p=0.00) and used incentive spirometry (76 v. 46%, p=0.00) thanreported previously. More respondents performed suctioning (99 v. 70%, p=0.00), extubation (60 v. 25%, p=0.00) and adjustment of MVsettings (30 v. 12%, p=0.02) than reported internationally.Conclusion. Physiotherapy practice in ICUs is evidence based. Care focuses largely on mobilisation, exercise therapy and multimodalityrespiratory therapy

‘If you have a problem with your heart, you have a problem with your life’: Self-perception and behaviour in relation to the risk of ischaemic heart disease in people living with HIV

Background: Ischaemic heart disease (IHD) is a global health problem and specifically relevant in the African context, as the presence of risk factors for IHD is increasing. People living with the human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) (PLWHA) are at increased risk for IHD due to increased longevity, treatment-specific causes and viral effects. Aim: To determine the self-perception and behaviour in relation to risk for IHD in a cohort of South African PLWHA.Methods:A qualitative study using semi-structured interviews with a card-sort technique was used to gather data from 30 individuals at an HIV clinic in Johannesburg. Descriptive analysis and conventional content analysis were done to generate the findings. Results: The median age of the cohort was 36.5 (31.8–45.0) years and they were mostly women (n = 25; 83.3%) who were employed (n = 17; 56.7%) and supporting dependents (n = 26; 86.7%). Fifteen (50%) participants did not perceive themselves at risk of IHD and reported having adequate coping behaviour, living a healthy lifestyle and being healthy since initiating therapy. Twelve (40%) did feel at risk because they experienced physical symptoms and had poor behaviour. Knowledge and understanding related to IHD, insight into own risk for IHD and health character in a context of HIV infection were three themes. Conclusion: This study highlights that participants did not perceive themselves to be at risk of IHD due to their HIV status or antiretroviral management. Education strategies are required in PLWHA to inform their personal risk perception for IHD

The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients : synthesis of evidence and expert opinion and its translation into practice

The original publication is available at http://cre.sagepub.com/content/early/2011/04/15/0269215510397677Includes bibliographyObjective: To facilitate knowledge synthesis and implementation of evidence supporting early physical activity and mobilization of adult patients in the intensive care unit and its translation into practice, we developed an evidence-based clinical management algorithm. Methods: Twenty-eight draft algorithm statements extracted from the extant literature by the primary research team were verified and rated by scientist clinicians (n¼7) in an electronic three round Delphi process. Algorithm statements which reached a priori defined consensus – semi-interquartile range <0.5 – were collated into the algorithm. Results: The draft algorithm statements were edited and six additional statements were formulated. The 34 statements related to assessment and treatment were grouped into three categories. Category A included statements for unconscious critically ill patients; Category B included statements for stable and cooperative critically ill patients, and Category C included statements related to stable patients with prolonged critical illness. While panellists reached consensus on the ratings of 94% (32/34) of the algorithm statements, only 50% (17/34) of the statements were rated essential.Medical Research Council of South AfricaPost-prin