Long-term cognitive impairment is common among ICU survivors, but its natural history remains unclear. In this systematic review, we report the frequency of cognitive impairment in ICU survivors across various time points after ICU discharge that were extracted from 46 of the 3,350 screened records. Prior studies used a range of cognitive instruments, including subjective assessments (10 studies), single or screening cognitive test such as Mini-Mental State Examination or Trail Making Tests A and B (23 studies), and comprehensive cognitive batteries (26 studies). The mean prevalence of cognitive impairment was higher with objective rather than subjective assessments (54% [95% confidence interval (CI), 51-57%] vs. 35% [95% CI, 29-41%] at 3 months after ICU discharge) and when comprehensive cognitive batteries rather than Mini-Mental State Examination were used (ICU discharge: 61% [95% CI, 38-100%] vs. 36% [95% CI, 15-63%]; 12 months after ICU discharge: 43% [95% CI, 10-78%] vs. 18% [95% CI, 10-20%]). Patients with acute respiratory distress syndrome had higher prevalence of cognitive impairment than mixed ICU patients at ICU discharge (82% [95% CI, 78-86%] vs. 48% [95% CI, 44-52%]). Although some studies repeated tests at more than one time point, the time intervals between tests were arbitrary and dictated by operational limitations of individual studies or chosen cognitive instruments. In summary, the prevalence and temporal trajectory of ICU-related cognitive impairment varies depending on the type of cognitive instrument used and the etiology of critical illness. Future studies should use modern comprehensive batteries to better delineate the natural history of cognitive recovery across ICU patient subgroups and determine which acute illness and treatment factors are associated with better recovery trajectories.
Purpose To evaluate the impact of the COVID-19 pandemic on Canadian intensive care unit (ICU) workers. Methods Between June and August 2020, we distributed a cross-sectional online survey of ICU workers evaluating the impact of the pandemic, coping strategies, symptoms of post-traumatic stress disorder (PTSD; Impact of Events Scale-Revised), and psychological distress, anxiety, and depression (Kessler Psychological Distress Scale). We performed regression analyses to determine the predictors of psychological symptoms. Results We analyzed responses from 455 ICU workers (80% women; 67% from Ontario; 279 nurses, 69 physicians, and 107 other healthcare professionals). Respondents felt that their job put them at great risk of exposure (60%), were concerned about transmitting COVID-19 to family members (76%), felt more stressed at work (67%), and considered leaving their job (37%). Overall, 25% had probable PTSD and 18% had minimal or greater psychological distress. Nurses were more likely to report PTSD symptoms (33%) and psychological distress (23%) than physicians (5% for both) and other health disciplines professionals (19% and 14%). Variables associated with PTSD and psychological distress included female sex (beta-coefficient [B], 1.59; 95% confidence interval [CI], 1.20 to 2.10 and B, 3.79; 95% CI, 1.79 to 5.78, respectively; P < 0.001 for differences in scores across groups) and perceived increased risk due to PPE shortage or inadequate PPE training (B, 1.87; 95% CI, 1.51 to 2.31 and B, 4.88; 95% CI, 3.34 to 6.43, respectively). Coping strategies included talking to friends/family/colleagues (80%), learning about COVID-19 (78%), and physical exercise (68%). Over half endorsed the following workplace strategies as valuable: hospital-provided scrubs, clear communication and protocols by hospitals, knowing their voice is heard, subsidized parking, and gestures of appreciation from leadership. Conclusions This survey study shows that ICU workers have been impacted by the COVID-19 pandemic with high levels of stress and psychological burden. Respondents endorsed communication, protocols, and appreciation from leadership as helpful mitigating strategies. Supplementary Information The online version contains supplementary material available at 10.1007/s12630-021-02175-z.
Objectives We aimed to evaluate the personal, professional, and psychological impact of the COVID-19 pandemic on hospital workers and their perceptions about mitigating strategies. Design Cross-sectional web-based survey consisting of (1) a survey of the personal and professional impact of the COVID-19 pandemic and potential mitigation strategies, and (2) two validated psychological instruments (Kessler Psychological Distress Scale [K10] and Impact of Events Scale Revised [IES-R]). Regression analyses were conducted to identify the predictors of workplace stress, psychological distress, and post-traumatic stress. Setting and participants Hospital workers employed at 4 teaching and 8 non-teaching hospitals in Ontario, Canada during the COVID-19 pandemic. Results Among 1875 respondents (84% female, 49% frontline workers), 72% feared falling ill, 64% felt their job placed them at great risk of COVID-19 exposure, and 48% felt little control over the risk of infection. Respondents perceived that others avoided them (61%), reported increased workplace stress (80%), workload (66%) and responsibilities (59%), and 44% considered leaving their job. The psychological questionnaires revealed that 25% had at least some psychological distress on the K10, 50% had IES-R scores suggesting clinical concern for post-traumatic stress, and 38% fulfilled criteria for at least one psychological diagnosis. Female gender and feeling at increased risk due to PPE predicted all adverse psychological outcomes. Respondents favoured clear hospital communication (59%), knowing their voice is heard (55%), expressions of appreciation from leadership (55%), having COVID-19 protocols (52%), and food and beverages provided by the hospital (50%). Conclusions Hospital work during the COVID-19 pandemic has had important personal, professional, and psychological impacts. Respondents identified opportunities to better address information, training, and support needs.
Purpose: Passive in-bed cycling (PC) can provide the benefits of early mobilization to critically ill patients who are unable to exercise actively. However, the effect of PC on global hemodynamics and perfusion of ischemia-prone organs, such as the brain and the heart, is unknown. Therefore, prior to studying the effects of PC in hemodynamically fragile critically ill patients, we characterized hemodynamic, brain blood flow, and cardiac function responses to a graded increase in PC cadence in a cohort of healthy subjects.Methods: We measured global hemodynamic indices, middle cerebral artery velocity (MCAv), and cardiac function in response to a graded increase in PC cadence. Using 5 min stages, we increased cadence from 5 to 55 RPM in increments of 10 RPM, preceded and followed by 5 min baseline and recovery periods at 0 RPM. The mean values obtained during the last 2 min of each stage were compared within and between subjects for all metrics using repeated measures ANOVA.Results: 11 healthy subjects (6 females) completed the protocol. Between subjects, there was no change in MCAv, cardiac function or hemodynamics with the graded increase in cadence with one exception. There was a 7% increase in mean arterial pressure (MAP) from baseline to 55RPM, that persisted through the recovery period. Across subjects, responses were heterogeneous, with some experiencing reduction in cardiac index, cerebral blood flow (CBF) and cardiac function, especially at higher cadence.Conclusions: In healthy adults, increasing PC cadence increased MAP in all subjects, while cardiac index, CBF, and cardiac function responses varied between subjects. Application of PC to critically ill patients must therefore consider individual variation in responses and tailor the PC to the patient. It is essential to further characterize these responses to PC in the critically ill prior to wide-scale clinical implementation.
Background: In-bed passive cycling is considered a safe and feasible early mobilization technique in intensive care unit (ICU) patients who are unable to exercise actively. However, the impact of varying intensity of passive cycling on perfusion and function of ischemia-prone organs is unknown. In this study, we assessed the impact of a graded passive cycling protocol on hemodynamics, cerebral blood flow, and cardiac function in a cohort of septic ICU patients. Methods: In consecutive patients presenting with sepsis, we measured global hemodynamic indices, middle cerebral artery velocity (MCAv), and cardiac function in response to a graded increase in passive cycling cadence. Using 5-min stages, we increased cadence from 5 to 55 RPM in increments of 10 RPM, preceded and followed by 5 min baseline and recovery periods at 0 RPM. The mean values obtained during the last 2 min of each stage were compared within and between subjects for all metrics using repeated-measures ANOVA. Results: Ten septic patients (six males) completed the protocol. Across patients, there was a 5.2% reduction in MCAv from baseline at cycling cadences of 25-45 RPM with a dose-dependent decrease of MCAv of > 10% in four of the 10 patients enrolled. There was a 16% increase in total peripheral resistance from baseline at peak cadence of 55 RPMs and no changes in any other measured hemodynamic parameters. Patient responses to passive cycling varied between patients in terms of magnitude, direction of change, and the cycling cadence at which these changes occurred. Conclusions: In septic patients, graded passive cycling is associated with dose-dependent decreases in cerebral blood flow, increases in total peripheral resistance, and either improvement or worsening of left ventricular function. The magnitude and cadence threshold of these responses vary between patients. Future studies should establish whether these changes are associated with clinical outcomes, including cognitive impairment, vasopressor use, and functional outcomes.
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