The latest medical research on Critical Care

Long-term outcomes of patients with severe acute brain injury (SABI) and their surrogate decision makers (SDMs) are insufficiently explored.

We conducted a prospective, single-center, observational study of patients with SABI who required mechanical ventilation between September and November 2021. Two telephonic interviews were conducted at 6-12 months and 18-24 months post SABI. Patients' functional outcomes at both time points were measured on the Glasgow Outcome Scale-Extended and categorized as dead (1), dependent (2-4), or independent (5-8). SDMs were interviewed at 18-24 months using validated screening tools for depression, anxiety, and posttraumatic stress disorder and qualitative questions about the hardest challenges during their recovery journey.

We included 103 patients (median age 58 years, 28% female, 77% White, 51% with stroke, 49% with traumatic brain injury); in-hospital mortality was 46%. At 6-12 months and 18-24 months, 34% and 36% were independent, respectively; the Glasgow Outcome Scale-Extended score improved ≥ 1 point for 32% between time points. Quality of life was perceived as acceptable for 47% of all survivors and 58% of independent patients by their SDMs. At 18-24 months, we reached 56 SDMs (median age 58 years, 71% female, 72% White). Symptoms of depression, anxiety, and posttraumatic stress disorder were reported in 18%, 30%, and 7%, respectively (23%, 34%, and 9% in the 35 SDMs of survivors and 10%, 24%, and 5% in the 21 SDMs to deceased patients). Main themes about challenges for patients and SDMs included extrinsic factors related to the health care system, and intrinsic factors related to the brain injury: difficulties in adapting to a new state, mental health symptoms, and social isolation.

Mental health symptoms among SDMs of patients with SABI were frequent at 18-24 months, and the patients' quality of life was deemed unacceptable for 42% of SDMs to independent survivors. Our findings underscore the need for psychosocial support to SDMs, the importance of addressing modifiable barriers to patient and SDM well-being, and the need for more patient/family-centric outcome measures.

Pediatric patients with advanced heart disease (AHD) often receive high intensity medical care at the end of life (EOL). In this study, we aimed to determine whether receipt and timing of pediatric palliative care (PPC) consultation was associated with EOL care intensity of pediatric patients with AHD.

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We compared demographics, EOL characteristics and care, including medical interventions and mortality characteristics for patients by receipt and timing of PPC (i.e., ≥ 30 d from [early] or < 30 d of death [late]) using chi-square and Wilcoxon rank-sum tests. Of 218 patients, 78 (36%) did not receive PPC, 76 received early PPC (35%), and 64 received late PPC (29%). Compared with patients who did not receive PPC, patients receiving PPC had lower EOL care intensity (77% vs. 96%; p = 0.004) and fewer invasive interventions within 14 days of death (74% vs. 92%; p = 0.004). Receipt of PPC, vs. not, was associated with lower rate of death during cardiopulmonary resuscitation (12% vs. 32%; p = 0.004) and more use of comfort care (23% vs. 3%; p = 0.004). Among patients receiving PPC, early PPC was associated with fewer invasive interventions within 14 days of death (65% vs. 85%; p = 0.033). Care intensity was high for patients with early and late PPC.

Early PPC was associated with fewer invasive interventions within 14 days of death, yet the care intensity at EOL remained high. With early PPC, families likely receive timely psychosocial and advance care planning support without significantly altering goals of care.

To summarize current data regarding the prevalence, risk factors, consequences, assessment and treatment of dyspnea in critically ill patients receiving invasive mechanical ventilation.

In intubated patients, dyspnea is frequent, perceived as intense, and associated with unfavorable outcomes such as immediate and unbearable distress (e.g. fear of dying), prolonged weaning, and delayed severe psychological consequences ( i.e. posttraumatic stress disorders). In noncommunicative patients, dyspnea is named respiratory-related brain suffering (RRBS) and can be detected using dyspnea observations scales. Before initiating pharmacological treatments, nonpharmacological interventions may be tried as they are efficient to alleviate dyspnea.

As opposed to pain, dyspnea has often been overlooked in terms of detection and management, resulting in its significant underestimation in daily practice. When it is diagnosed, dyspnea can be relieved through straightforward interventions, such as adjusting ventilator settings. Assessing dyspnea in patients undergoing invasive mechanically ventilated may be challenging, especially in noncommunicative patients (RRBS). Implementing a systematic dyspnea assessment in routine, akin to pain, could serve as a first step to reduce RRBS and prevent potential severe psychological consequences. In addition to pharmacological treatments like opioids, a promising approach is to modulate both the sensory (air on the face, trigeminal nerve stimulation) and the affective (relaxing music, hypnosis, directed empathy) components of dyspnea.

Mechanical ventilation may have adverse effects on diaphragm and lung function. Lung- and diaphragm-protective ventilation is an approach that challenges the clinician to facilitate physiological respiratory efforts, while maintaining minimal lung stress and strain. Here, we discuss the latest advances in monitoring and interventions to achieve lung- and diaphragm protective ventilation.

Noninvasive ventilator maneuvers (P0.1, airway occlusion pressure, pressure-muscle index) can accurately detect low and excessive respiratory efforts and high lung stress. Additional monitoring techniques include esophageal manometry, ultrasound, electrical activity of the diaphragm, and electrical impedance tomography. Recent trials demonstrate that a systematic approach to titrating inspiratory support and sedation facilitates lung- and diaphragm protective ventilation. Titration of positive-end expiratory pressure and, if available, veno-venous extracorporeal membrane oxygenation sweep gas flow may further modulate neural respiratory drive and effort to facilitate lung- and diaphragm protective ventilation.

Achieving lung- and diaphragm-protective ventilation may require more than a single intervention; it demands a comprehensive understanding of the (neuro)physiology of breathing and mechanical ventilation, along with the application of a series of interventions under close monitoring. We suggest a bedside-approach to achieve lung- and diaphragm protective ventilation targets.