The contribution of frailty, cognition, activity of daily life and comorbidities on outcome in acutely admitted patients over 80 years in European ICUs:the VIP2 study

Purpose: Premorbid conditions affect prognosis of acutely-ill aged patients. Several lines of evidence suggest geriatric syndromes need to be assessed but little is known on their relative effect on the 30-day survival after ICU admission. The primary aim of this study was to describe the prevalence of frailty, cognition decline and activity of daily life in addition to the presence of comorbidity and polypharmacy and to assess their influence on 30-day survival. Methods: Prospective cohort study with 242 ICUs from 22 countries. Patients 80 years or above acutely admitted over a six months period to an ICU between May 2018 and May 2019 were included. In addition to common patients’ characteristics and disease severity, we collected information on specific geriatric syndromes as potential predictive factors for 30-day survival, frailty (Clinical Frailty scale) with a CFS &gt; 4 defining frail patients, cognitive impairment (informant questionnaire on cognitive decline in the elderly (IQCODE) with IQCODE ≥ 3.5 defining cognitive decline, and disability (measured the activity of daily life with the Katz index) with ADL ≤ 4 defining disability. A Principal Component Analysis to identify co-linearity between geriatric syndromes was performed and from this a multivariable model was built with all geriatric information or only one: CFS, IQCODE or ADL. Akaike’s information criterion across imputations was used to evaluate the goodness of fit of our models. Results: We included 3920 patients with a median age of 84 years (IQR: 81–87), 53.3% males). 80% received at least one organ support. The median ICU length of stay was 3.88 days (IQR: 1.83–8). The ICU and 30-day survival were 72.5% and 61.2% respectively. The geriatric conditions were median (IQR): CFS: 4 (3–6); IQCODE: 3.19 (3–3.69); ADL: 6 (4–6); Comorbidity and Polypharmacy score (CPS): 10 (7–14). CFS, ADL and IQCODE were closely correlated. The multivariable analysis identified predictors of 1-month mortality (HR; 95% CI): Age (per 1 year increase): 1.02 (1.–1.03, p = 0.01), ICU admission diagnosis, sequential organ failure assessment score (SOFA) (per point): 1.15 (1.14–1.17, p &lt; 0.0001) and CFS (per point): 1.1 (1.05–1.15, p &lt; 0.001). CFS remained an independent factor after inclusion of life-sustaining treatment limitation in the model. Conclusion: We confirm that frailty assessment using the CFS is able to predict short-term mortality in elderly patients admitted to ICU. Other geriatric syndromes do not add improvement to the prediction model. Since CFS is easy to measure, it should be routinely collected for all elderly ICU patients in particular in connection to advance care plans, and should be used in decision making.</p

Quantitative assessment of required separator fluid volume in multi-infusion settings

Background: Administering a separator fluid between incompatible solutions can optimize the use of intravenous lumens. Factors affecting the required separator fluid volume to safely separate incompatible solutions are unknown. Methods: An intravenous tube (2-m, 2-mL, 6-French) containing methylene blue dye was flushed with separator fluid until a methylene blue concentration ⩽2% from initial was reached. Independent variables were administration rate, dye solvent (glucose 5% and NaCl 0.9%), and separator fluid. In the second part of the study, methylene blue, separator fluid, and eosin yellow were administered in various administration profiles using 2- and 4-mL (2 × 2 m, 4-mL, 6-French) intravenous tubes. Results: Neither administration rate nor solvent affected the separator fluid volume (p = 0.24 and p = 0.12, respectively). Glucose 5% as separator fluid required a marginally smaller mean ± SD separator fluid volume than NaCl 0.9% (3.64 ± 0.13 mL vs 3.82 ± 0.11 mL, p < 0.001). Using 2-mL tubing required less separator fluid volume than 4-mL tubing for methylene blue (3.89 ± 0.57 mL vs 4.91 ± 0.88 mL, p = 0.01) and eosin yellow (4.41 ± 0.56 mL vs 5.63 ± 0.15 mL, p < 0.001). Extended tubing required less separator fluid volume/mL of tubing than smaller tubing for both methylene blue (2 vs 4 mL, 1.54 ± 0.22 vs 1.10 ± 0.19, p < 0.001) and eosin yellow (2 vs 4 mL, 1.75 ± 0.22 vs 1.25 ± 0.03, p < 0.001). Conclusion: The separator fluid volume was neither affected by the administration rate nor by solvent. Glucose 5% required a marginally smaller separator fluid volume than NaCl 0.9%, however its clinical impact is debatable. A larger intravenous tubing volume requires a larger separator fluid volume. However, the ratio of separator fluid volume to the tubing’s volume decreases as the tubing volume increases

Use of infrared thermography in the detection of superficial phlebitis in adult intensive care unit patients:A prospective single-center observational study

Common methods to detect phlebitis may not be sufficient for patients in the intensive care unit (ICU). The goal of this study was to investigate the feasibility of infrared (IR) thermography to objectively detect phlebitis in adult ICU patients. We included a total of 128 adult ICU-patients in a pilot and subsequent validation study. Median [interquartile range] age was 62 [54-71] years and 88 (69%) patients were male. Severity of phlebitis was scored using the visual infusion phlebitis (VIP)-score, ranging from 0 (no phlebitis) to 5 (thrombophlebitis). The temperature difference (ΔT) between the insertion site and a proximal reference point was measured with IR thermography. In 78 (34%) catheters early phlebitis and onset of moderate phlebitis was observed (VIP-score of 1-3). In both the pilot and the validation study groups ΔT was significantly higher when the VIP-score was ≥1 compared to a VIP-score of 0 (p<0.01 and p<0.001, respectively). Multivariate analysis identified ΔT (p<0.001) and peripheral venous catheter (PVC) dwell time (p = 0.001) as significantly associated with phlebitis. IR thermography may be a promising technique to identify phlebitis in the ICU. An increased ΔT as determined with thermography may be a risk factor for phlebitis

Comparison of temperature measurements in bladder, rectum and pulmonary artery in patients after cardiac surgery

In many patients in the intensive care unit (ICU) continuous temperature monitoring is performed with rectal probes. Currently there are more options to measure temperature in critically ill patients. Since bladder catheters are routinely used in the majority of ICU patients, using bladder temperature (Tb) could do away with rectal probes. In this prospective study, we compared Tb, rectal temperature (Tr) and pulmonary artery catheter temperature (Tpa) in pa-tients who underwent cardiac surgery. We also evaluated if urinary production affected Tb. Patients admitted after cardiac surgery with sensors in place for measurement of Tr, Tb and Tpa upon arrival at the ICU were included. Diuresis was recorded every hour. Data were collected until 24 h after admission or until ICU discharge. Nineteen consecutive patients (9 males; mean age 61 years) were evaluated. Over a median observation period of 17 hours 382 Tb, 333 Tr and 371 Tpa measurements were recorded. Linear correlations (R) between Tb and Tr, between Tb and Tpa and between Tr and Tpa were 0.95, 0.95 and 0.91 respectively (P < 0.001). Bland-Altman analysis demonstrated no relation between temperature and the (Tb-Tr) offset. No relation of diuresis with (Tb- Tr) or (Tb-Tpa) was observed. After cardiac surgery, bladder temperature performed as well as conven-tional rectal probes with no interference of diuresis on bladder temperature measurement. Thus, the use of bladder temperature probes may be preferable to rectal probes in patients after cardiac surgery

Temporal artery temperature measurements versus bladder temperature in critically ill patients, a prospective observational study

PurposeAccurate measurement of body temperature is important for the timely detection of fever or hypothermia in critically ill patients. In this prospective study, we evaluated whether the agreement between temperature measurements obtained with TAT (test method) and bladder catheter-derived temperature measurements (BT; reference method) is sufficient for clinical practice in critically ill patients.MethodsPatients acutely admitted to the Intensive Care Unit were included. After BT was recorded TAT measurements were performed by two independent researchers (TAT1; TAT2). The agreement between TAT and BT was assessed using Bland-Altman plots. Clinical acceptable limits of agreement (LOA) were defined a priori (ResultsIn total, 90 critically ill patients (64 males; mean age 62 years) were included. The observed mean difference (TAT-BT; ±SD, 95% LOA) between TAT and BT was 0.12°C (-1.08°C to +1.32°C) for TAT1 and 0.14°C (-1.05°C to +1.33°C) for TAT2. 36% (TAT1) and 42% (TAT2) of all paired measurements failed to meet the acceptable LOA of 0.5°C. Subgroup analysis showed that when patients were receiving intravenous norepinephrine, the measurements of the test method deviated more from the reference method (p = NS).ConclusionThe TAT is not sufficient for clinical practice in critically ill adults

Intensive care unit depth of sleep:proof of concept of a simple electroencephalography index in the non-sedated

INTRODUCTION: Intensive care unit (ICU) patients are known to experience severely disturbed sleep, with possible detrimental effects on short- and long- term outcomes. Investigation into the exact causes and effects of disturbed sleep has been hampered by cumbersome and time consuming methods of measuring and staging sleep. We introduce a novel method for ICU depth of sleep analysis, the ICU depth of sleep index (IDOS index), using single channel electroencephalography (EEG) and apply it to outpatient recordings. A proof of concept is shown in non-sedated ICU patients. METHODS: Polysomnographic (PSG) recordings of five ICU patients and 15 healthy outpatients were analyzed using the IDOS index, based on the ratio between gamma and delta band power. Manual selection of thresholds was used to classify data as either wake, sleep or slow wave sleep (SWS). This classification was compared to visual sleep scoring by Rechtschaffen & Kales criteria in normal outpatient recordings and ICU recordings to illustrate face validity of the IDOS index. RESULTS: When reduced to two or three classes, the scoring of sleep by IDOS index and manual scoring show high agreement for normal sleep recordings. The obtained overall agreements, as quantified by the kappa coefficient, were 0.84 for sleep/wake classification and 0.82 for classification into three classes (wake, non-SWS and SWS). Sensitivity and specificity were highest for the wake state (93% and 93%, respectively) and lowest for SWS (82% and 76%, respectively). For ICU recordings, agreement was similar to agreement between visual scorers previously reported in literature. CONCLUSIONS: Besides the most satisfying visual resemblance with manually scored normal PSG recordings, the established face-validity of the IDOS index as an estimator of depth of sleep was excellent. This technique enables real-time, automated, single channel visualization of depth of sleep, facilitating the monitoring of sleep in the ICU

Coping strategies, anxiety and depressive symptoms in family members of patients treated with extracorporeal membrane oxygenation:A prospective cohort study

BACKGROUND: Family members of patients treated with Extracorporeal Membrane Oxygenation (ECMO) during an Intensive Care Unit (ICU) stay are at risk of developing symptoms of anxiety, depression and Post-Traumatic Stress Disorder (PTSD). Coping strategies used by family members may play an important role in the severity of some of these symptoms.OBJECTIVES: The primary aim of this study was to describe coping strategies used by family members of ECMO-treated patients during ICU admission and recovery period. The secondary aim was to explore the course of the symptoms anxiety, depression, PTSD, and Health Related Quality Of Life (HRQOL) over time.METHODS: In this single-center prospective longitudinal study, validated questionnaires were used to measure coping strategies, symptoms of anxiety, depression and PTSD, and HRQOL in family members of ECMO-treated patients directly after the start of ECMO and at one and six months after the start of ECMO.RESULTS: Family members (n = 26) mainly used problem-focused coping strategies. Symptoms of anxiety appeared to be most present during treatment but decreased over time, as did symptoms of depression and PTSD. HRQOL was severely affected, especially in the mental domain, and did not improve over time.CONCLUSION: In family members of ECMO-treated patients, problem-focused coping mechanisms were most prominent. Psychological functioning was impaired on admission but improved over time, although a mild reaction to stress remained.</p