Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med 2009; 37:2499–505
Clinical peripheral muscle weakness has been reported in 25–33% of patients mechanically ventilated for 4 to 7 days. This may lead to prolonged intensive care unit (ICU) stays and impaired functional status and quality of life up to 1 yr after discharge. Recent evidence suggests that early activity is possible for critically ill patients; however, there is limited evidence for its effectiveness in patients in ICUs while under sedation.
A randomized controlled trial was conducted to investigate whether a daily exercise session is a safe and an effective intervention in preventing or attenuating these detrimental effects. Critically ill patients (N = 90) were included when their cardiorespiratory condition allowed (beginning day 5) and if a prolonged ICU stay (at least 7 more days) was expected. Patients received respiratory physiotherapy and a daily standardized passive or active motion session of upper and lower limbs and the treatment group performed a passive or active bedside cycling session for 20 min/day.
Most patients (79%) were recruited in the surgical ICU and of these most had undergone cardiac surgery (39%), transplant surgery (25%), or thoracic surgery (16%). Eighty percent of patients received assisted pressure-support ventilation. The median number of cycling sessions was 7 and the median cycling frequency was 4 sessions/week. No severe adverse events were identified during and immediately after the exercise training.
At hospital discharge, all outcomes (e.g. , 6-min walking distance, isometric quadriceps force, and the subjective feeling of functional well-being) were significantly higher in the treatment group (P < 0.05).
This study confirms that exercise should be considered even in surgical patients, provided patients are evaluated for contraindications and monitored during exercise sessions. Muscle strength and functional ability are improved in the muscle territories activated by the cycling exercise. Whether early mobility and occupational therapy are feasible, safe and effective in surgical patients with wounds and multiple drains is not known. Nevertheless, exercise cycling represents a first step toward addressing muscle inactivity while patients are receiving mechanical ventilation.
Suggested by: Bernard De Jonghe, M.D.
Plasma tryptophan and tyrosine levels are independent risk factors of delirium in critically ill patients. Intensive Care Med 2009; 35:1886–92
Delirium may occur in as few as 20% or as many as 80% of patients in the ICU. This preventable problem may result in prolonged hospitalization, increased costs, mortality, and potential long-term problems. Although the pathophysiology of delirium remains elusive, changes in neurotransmission by serotonin, dopamine, acetylcholine, and norepinephrine using pathways may play a role. This pilot study was conducted to investigate the role of precursor large neutral amino acids such as tryptophan, phenylalanine, and tyrosine and risk of transitioning to delirium in critically ill patients.
Plasma large neutral amino acids concentrations were determined on days 1 and 3 in mechanically ventilated patients from the Maximizing Efficacy of Targeted Sedation and Reducing Neurological Dysfunction randomized controlled trial comparing dexmedetomidine and lorazepam sedation. Delirium was assessed daily using the confusion assessment method for the ICU.
At baseline, all evaluable patients (n = 97) had a high severity of illness (median Acute Physiology and Chronic Health Evaluation [APACHE] II, 28) and most were admitted for sepsis or acute respiratory distress syndrome (42%). After adjusting for confounders, only high or low tryptophan/large neutral amino acids ratios (P = 0.0003), and tyrosine/large neutral amino acids ratios (P = 0.02) were associated with increased risk of transitioning to delirium. Additional predictors included older age, higher APACHE II scores, and increased fentanyl exposure.
This study strengthens the view that alterations in the metabolism of amino acids such as tryptophan (via serotonin) and tyrosine (via dopamine or norepepinephrine) contribute to the pathophysiology of delirium in patients in the ICU. This pilot study needs confirmation by future, methodologically robust, prospective trials but provides both pathophysiologic and therapeutic insights for preventing and treating delirium in patients in the ICU.
Antiplatelet drugs and outcome in mixed admissions to an intensive care unit. Crit Care Med 2010; 38:32–7
Activation of circulating blood platelets results in their sequestration in the microvasculature and thrombocytopenia, and these are common features of sepsis, a leading cause of death in critically ill patients. Antiplatelet agents may provide a benefit through modulation of inflammatory responses in critically ill patients; however, because of an increased risk of bleeding, the risk–benefit ratio must be examined closely.
A retrospective cohort study was conducted, which analyzed 615 consecutive patients admitted to an ICU within 24 h after hospitalization. Approximately 25% of patients received antiplatelet drugs (acetylsalicylic acid or clopidogrel).
The majority of patients were enrolled primarily to the ICU from the local emergency department (52%) or local internal medicine or surgical departments (19%). Approximately 60% of patients had active bleeding at admission or during the ICU stay. Patients who received antiplatet drugs were markedly older and presented higher APACHE II scores on ICU admission.
Overall, no differences were observed between groups for length of ICU stay, frequency of infections, sepsis, or mechanical ventilation. Regression analysis to control for differences in APACHE II scores and age showed a significant improvement in mortality in patients with preexistent antiplatelet medication use. Benefits were higher in surgical patients.
Management of antiplatelet therapy is a complex issue in critically ill patients, because it requires careful evaluation of the bleeding versus thrombotic risk in patients with organ failure. These data are the first to suggest that, in some critically ill patients, antiplatelet drugs may decrease mortality, perhaps by preventing microvascular thrombosis and organ failure. If confirmed in future prospective, randomized trials, these findings may have an important impact for daily routine practice in ICU patients.
Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA 2009; 302:2671–8
Onsite staffing by intensivists in ICUs is associated with reduced morbidity and mortality; however, this may not always be possible. Therefore, remote telemedicine technology, which enables intensivists to simultaneously monitor several ICUs from an off-site location, has become increasingly common. However, this technology is expensive, and there is little data evaluating its effectiveness.
This observational study was conducted in six ICUs at five hospitals in a large U.S. healthcare system to assess the use of tele-ICU in 2,034 patients in a preintervention period (before tele-ICU) and 2,108 patients in the postintervention (after tele-ICU implementation) period. Local physicians delegated full treatment authority to the tele-ICU for 655 patients (31.1%) and authority to intervene only in life-threatening events for the remainder of patients.
Hospital mortality rates were 12.0 and 9.9% and ICU mortality rates were 9.2 and 7.8% in the preintervention and postintervention periods, respectively. After adjustment for severity of illness, no significant differences were associated with the telemedicine intervention for hospital mortality (relative risk, 0.85) or for ICU mortality (relative risk, 0.88). Tele-ICU intervention was significantly associated with improved survival in more sick patients but with no improvement or worse outcomes in less sick patients. Length of stay was similar in both groups.
It has not been determined whether telemedicine improves healthcare and reduces costs in ICU patients. Although remote monitoring of ICU patients was not associated with an overall improvement in mortality or length of stay, the complexity of ICU patients is a major issue when evaluating the contribution of telemedicine-ICU in improving outcome versus conventional ICU staffing.