Objective:To revise the “Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult” published in Critical Care Medicine in 2002.Methods:The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task f

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Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit

This document represents the first collaboration between 2 organizations-the American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine-to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric critically ill patient (>1 month and 2-3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2032 citations were scanned for relevance. The PubMed/MEDLINE search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1661 citations. In total, the search for clinical trials yielded 1107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer 1 of the 8 preidentified question groups for this guideline. We used the GRADE criteria (Grading of Recommendations, Assessment, Development, and Evaluation) to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutrition assessment-particularly, the detection of malnourished patients who are most vulnerable and therefore may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery are areas of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)

The first suggestion that physical exercise results in free radical-mediated damage to tissues appeared in 1978, and the past three decades have resulted in a large growth of knowledge regarding exercise and oxidative stress. Although the sources of oxidant production during exercise continue to be debated, it is now well established that both resting and contracting skeletal muscles produce reactive oxygen species and reactive nitrogen species. Importantly, intense and prolonged exercise can result in oxidative damage to both proteins and lipids in the contracting myocytes. Furthermore, oxidants can modulate a number of cell signaling pathways and regulate the expression of multiple genes in eukaryotic cells. This oxidant-mediated change in gene expression involves changes at transcriptional, mRNA stability, and signal transduction levels. Furthermore, numerous products associated with oxidant-modulated genes have been identified and include antioxidant enzymes, stress proteins, DNA repair proteins, and mitochondrial electron transport proteins. Interestingly, low and physiological levels of reactive oxygen species are required for normal force production in skeletal muscle, but high levels of reactive oxygen species promote contractile dysfunction resulting in muscle weakness and fatigue. Ongoing research continues to probe the mechanisms by which oxidants influence skeletal muscle contractile properties and to explore interventions capable of protecting muscle from oxidant-mediated dysfunction.

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Exercise-induced oxidative stress: cellular mechanisms and impact on muscle force production

Background There have been few detailed, in-person interviews and examinations to obtain follow-up data on 5-year outcomes among survivors of the acute respiratory distress syndrome (ARDS). Methods We evaluated 109 survivors of ARDS at 3, 6, and 12 months and at 2, 3, 4, and 5 years after discharge from the intensive care unit. At each visit, patients were interviewed and examined; underwent pulmonary-function tests, the 6-minute walk test, resting and exercise oximetry, chest imaging, and a quality-of-life evaluation; and reported their use of health care services. Results At 5 years, the median 6-minute walk distance was 436 m (76% of predicted distance) and the Physical Component Score on the Medical Outcomes Study 36-Item Short-Form Health Survey was 41 (mean norm score matched for age and sex, 50). With respect to this score, younger patients had a greater rate of recovery than older patients, but neither group returned to normal predicted levels of physical function at 5 years. Pulmonary function wa...

Functional disability 5 years after acute respiratory distress syndrome.

Background As more patients survive the acute respiratory distress syndrome, an understanding of the long-term outcomes of this condition is needed. Methods We evaluated 109 survivors of the acute respiratory distress syndrome 3, 6, and 12 months after discharge from the intensive care unit. At each visit, patients were interviewed and underwent a physical examination, pulmonary-function testing, a six-minute–walk test, and a quality-of-life evaluation. Results Patients who survived the acute respiratory distress syndrome were young (median age, 45 years) and severely ill (median Acute Physiology, Age, and Chronic Health Evaluation score, 23) and had a long stay in the intensive care unit (median, 25 days). Patients had lost 18 percent of their base-line body weight by the time they were discharged from the intensive care unit and stated that muscle weakness and fatigue were the reasons for their functional limitation. Lung volume and spirometric measurements were normal by 6 months, but carbon monoxide d...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa022450

One-Year Outcomes in Survivors of the Acute Respiratory Distress Syndrome

In the care of the critically ill patient a concept termed “immunonutrition” has developed to imply a nutritional formulation that promotes or beneficially modulates the immune system. A number of nutrients have come to be known as immunonutrients of which glutamine, arginine, ornithine–a–ketoglutarate (OKG) and w-3 fatty acids have been the most extensively studied, but the list could also include nucleotides, trace minerals such as selenium, or even probiotic bacteria. This short review, predominantly focusing on amino acids, discusses what evidence exists on whether the route of administration of nutrients can effect their clinical action.

Effects of Route and Dose of Immunonutrition Compounds

The potential role of nutrition to influence survival in the critically-ill is discussed. Increasing benefits are described to enteral nutrition but there remain some patients who have high mortality in whom only parenteral nutrition is possible. The clinical relevance of glutamine in parenteral nutrition is reviewed in the context of how it might influence survival from severe illness.

Nutrition and survival in intensive care

As we move from not simply saving but to fully recovering the lives of our patients, the devastating consequences that a critical illness reaps for some patients and families becomes apparent (1). In a move to bring together the view points of various stakeholders, the Society of Critical Care Medicine held a 2-day conference, the report of which is published in this issue of Critical Care Medicine (2). Principally drawn from North America, the experts examined the evidence on long-term consequences and, importantly, what can be performed to improve this for both patient and their families. Rightly, they point out the need to raise the awareness of the considerable challenges through education and the needs to address the barriers to best practice and to identify the research gaps that must be filled to help develop the best care. This is an important milestone in critical care thinking that emphasizes our responsibility to research and explore all aspects of a patient’s care so that what we do within and after the intensive care unit (ICU) can bring their well-being back to the best that is possible. This requires a cultural shift in ICU care that is not only focused on the immediacy of the clinical problem but also expands to accommodate the wider implications of recovery and the family. Essential to this is the realization that what we do within the ICU matters in the long-term. Twenty-five years ago, when I first started researching and exploring ways to improve the recovery of my patients, the level of interest for longer-term issues was muted. Some referees from major grant funders even considered it “not of relevance to intensive care;” however, fortunately across Europe, interested groups of doctors, nurses, and physiotherapists were recognizing the later problems and through collaborative research projects have allowed many lessons to be learned. Our collective experience shows that to best recover lives there needs to be a cultural change in ICU care, with a distinct early active and selective decision-making process with a therapeutic strategy starting within the ICU addressing physical and psychological needs that continues as patients move through the hospital and to home. It is selective to allow for the many particularly short-stay patients to foster normal recovery and coping but to support those usually longer-stay patients who need that support. This is summarized in U.K. guidelines suggesting that a clinical risk assessment and screening process should be maintained during an ICU stay and should be formalized on leaving the ICU to plan for the immediately apparent (e.g., weakness) and start screening for later developments (e.g., acute anxiety state) (3). Rehabilitation starts within the ICU not only because ICU-acquired weakness and the harmful consequence of excessive bed rest and immobility are now recognized (4). New ways of sedating, ventilating, and mobilizing patients are all important, but some of the key lessons learned are that psychological stress of both the patient and the family are confounders to later recovery (5), which may be ameliorated by taking preventive measures within the ICU. The outstanding North American research on acute brain dysfunction and later cognitive impairment (6, 7) has emphasized the considerable neurologic burden experienced. However, an acute consequence is that the disturbance of memory combined with abnormal perceptual and delusional experiences is a powerful precipitant of posttraumatic stress disorder, a major confounder of recovery. Fortunately, the realization that a patient and family diary collated during the ICU stay could be used therapeutically afterward to significantly reduce the development of posttraumatic stress disorder offers some hope for this devastating complication (8). The greatest practical implication is that in an event as catastrophic as a major critical illness, one must manage the patient and the family at all stages within and after the ICU to get optimal recovery. The patient and the family have different perspectives on the illness but are equally traumatized. In this report, I disagree with the idea that there is some unique “postintensive care syndrome.” This is a mistake they may come to regret. I can understand there is a need to promote an awareness of the many varied problems patients have after the ICU and some particularly long-stay patients may share them. However, it is not a distinct pathologic syndrome and I fear the adoption of a single term will lump together diverse problems that need specific research and diagnostic and therapeutic focus. I do not recall the useless term “ICU syndrome” ever promoting a research and therapeutic culture that advanced our care! Rehabilitation is part of routine ICU care and patients and families must be engaged to appreciate that this is “treatment” as important as any other. In the end, we are the mere guardians of the patient and we must foster and not damage the social support framework to which our patient will return. Richard D. Griffiths, MD, FRCP, FFICM Intensive Care Research Group Department of Musculoskeletal Biology II Institute of Ageing and Chronic Disease University of Liverpool Liverpool, UK

Rehabilitating the critically ill: a cultural shift in intensive care unit care.

Antidepressants are occasionally given to recovering intensive care (ICU) patients, either while in ICU, or shortly afterwards on the ward However there is little research on what characterizes these patients or their longer term psychological recovery As part of a larger rehabilitation study data were collected on the characteristics of ICU patients receiving antidepressants while in hospital and their progress up to 6 months post ICU Recovering ICU patients were approached once it was clear the patient was expected to survive to 6 months A record was made of antidepressant medication and depression was assessed using the Hospital Anxiety and Depression Scale (HAD) Psychological recovery was assessed at 2 and 6 months post ICU using the HAD1 and the Fear questionnaire2 to record panic attacks/phobias and physical recovery was similarly recorded using the SF-36 Seventy-six patients completed the HAD at 2 weeks, 2 months and 6 months post ICU All the patients had been intubated and had had an ICU stay ≥48 h, 18 had received antidepressants either in the ICU or shortly afterwards on the ward for a clinical diagnosis of depression Patients receiving antidepressants were much more likely to have had a longer ICU stay and a longer hospital stay (see Table 12) The fear questionnaire scores were not related directly to the length of ICU stay The questionnaire allows the examination of which particular areas patients are having difficulty with Patients receiving antidepressants were becoming panicky travelling alone, being alone in a busy street or far from home, and going shopping alone The data suggest that the use of antidepressants at times may be inappropriate The difficulty of establishing the diagnosis of depression in ICU may mean that only soft clinical criteria are used This is more likely to occur in longer stay patients Passivity due to a learned helplessness state may be diagnosed as depression while patients are intubated This would fit with these patients having difficulty performing activities alone Alternatively a subdued anxiety state may be similarly being misdiagnosed as depression

The characteristics of patients given antidepressants while recovering from critical illness

http://portlandpress.com/clinsci/article-pdf/73/s17/40P/879428/cs073040pc.pdf

Richard D. Griffiths

Papers

Effects of Route and Dose of Immunonutrition Compounds

Nutrition and survival in intensive care

Rehabilitating the critically ill: a cultural shift in intensive care unit care.

The characteristics of patients given antidepressants while recovering from critical illness

Metabolic Cost of Walking in Boys with Muscular Dystrophy