A Questionnaire on Satisfaction of Family Members during Family Issues Meetings in the Intensive Care Unit

Transcription

1 Quality Improvement A Questionnaire on Satisfaction of Family Members during Family Issues Meetings in the Intensive Care Unit Marnie Jakab, Sangeeta Mehta, Brittany Marinelli, Christina Nguyen, Andrea Moore, Nola Crewe, Christie M Lee Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada Introduction: ICU family meetings are an important method of communication between the ICU team and family; Family meetings play a key role in developing patient and family centered care. Objective: To identify key elements of an effective Family Meeting from a family perspective. Methods: A prospective exploratory study evaluating family members perceptions of trust, comfort, decision making and level of satisfaction of the ICU Family meeting. ICU family meetings include an attending physician, fellow, bedside nurse, chaplain, and social worker in addition to the family of the ICU patient. Any person attending the Family meeting on behalf of the patient was defined as a family member in this study. Between September 2013 and June 2014, all family members were offered a questionnaire for completion immediately following the Family meeting. The questionnaire asked family members about their satisfaction with the Family meeting relating to: physician ability to communicate, address questions, deliver information, and general satisfaction. Results: 100 Family meetings took place during the study period; 61 of these had at least one completed questionnaire returned, with a mean of 2.5 respondents per Family meeting. There were a total of 154 completed questionnaires. No questionnaires were completed in 39 Family meeting. Of the 154 respondents 59% were female; 21% self-identified as a child, 18% selfidentified as a parent, 18% self-identified as a spouse/partner, and over 20% were extended family. In general there is a high level of satisfaction in ICU FM (94.6%). There was a trend showing increased satisfaction rates in End of Life (EoL) discussions (98% vs 92%, p=0.088). There was no differences in satisfaction between males and females (64% vs 93%, p value = 0.241). There was a high level of perceived trust as 100% of respondents trusted the doctor either always or often and 99% said they trusted the ICU team always or often. Of those who always trusted both the doctor and the ICU team 4.8% were not satisfied with the meeting. The majority of respondents always felt comforted by the ICU team (77%), 21% responded sometimes and 3% felt they were not comforted during the meeting. There was a trend suggesting a higher proportion of respondents were not satisfied with decreasing comfort, however this was not statically significant. The majority surveyed preferred the doctor & family to make decisions together (87%). Conclusion: Family members taking part in ICU Family meetings are not limited to the traditional family unit. Family members that experience more comfort/trust towards the ICU team Page 1 of 8

2 are more satisfied with their Family meeting. Comfort may contribute more to family satisfaction than trust alone. EoL discussions remain an important part of the ICU Family meeting despite the sensitive nature of the conversation, families prefer a shared decision making model. Page 2 of 8

3 Physiology Evolution of Diaphragm Thickness During Mechanical Ventilation: Impact of Inspiratory Effort Ewan C Goligher 1,2,3,4, Eddy Fan 1,2,4,7, Margaret S. Herridge 1,2,4,10, Alistair Murray 1,4, Stefannie Vorona 1,4, Debbie Brace 1,4, Nuttapol Rittayamai 1,5, Ashley Lanys 1,4,5, George Tomlinson 2, Jeffrey M. Singh 1,2,4, Steffen-Sebastien Bolz 3, Gordon D. Rubenfeld 1,2,6,7, Brian P. Kavanagh 1,3,8,9, Laurent J. Brochard 1,2,5, Niall D Ferguson 1,2,3,4,7,10 Institutional Affiliations 1. Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada 2. Department of Medicine, University of Toronto, Toronto, Canada 3. Department of Physiology, University of Toronto, Toronto, Canada 4. Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada 5. Keenan Centre for Biomedical Research, St. Michael s Hospital, Toronto, Canada 6. Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada 7. Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada 8. Department of Anesthesia, University of Toronto, Toronto, Canada 9. Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Canada 10. Toronto General Research Institute, Toronto, Canada Introduction Adverse changes in diaphragm structure and function have been reported in mechanically ventilated patients but the prevalence of changes in diaphragm thickness in critically ill patients and the impact of mechanical ventilation are poorly defined. Objectives To determine if changes in diaphragm thickness and function are associated with the level of contractile activity during mechanical ventilation. Methods We enrolled 107 patients from 3 academic intensive care units following initiation of mechanical ventilation. Ten non-ventilated ICU patients were enrolled as controls. Subjects were followed for up to 2 weeks using daily ultrasound to measure diaphragm thickness and contractile activity (quantified by the inspiratory thickening fraction). Results Over the first week of ventilation, diaphragm thickness decreased by more than 10% in 47 (44%), was unchanged in 47 (44%), and increased by more than 10% in 13 (12%) (Figure 1). Thickness did not vary over time following extubation or in non-ventilated patients. Low diaphragm contractile activity was associated with rapid decreases in diaphragm thickness while high contractile activity was associated with increases in diaphragm thickness (p=0.002) (Figure 2). Contractile activity decreased with increasing ventilator driving pressure (p=0.01) and controlled modes of ventilation (p=0.02). Diaphragm function was significantly impaired in patients with either decreased or increased diaphragm thickness compared to patients with unchanged thickness (p=0.05) and controls (p=0.01). Page 3 of 8

4 Change in diaphragm thickness over time (% of baseline) Conclusions Changes in diaphragm thickness during mechanical ventilation are significantly influenced by diaphragm contractile activity. Both decreases and increases in diaphragm thickness are associated with impaired diaphragm function. Strategies to maintain normal respiratory effort during mechanical ventilation may prevent ventilator-associated diaphragm injury. +30% +20% % 13 0% Group: Diaphragm Thickness Change >10% loss on or before day 8 <10% change on or before day 8 >10% gain on or before day 8-10% % % Day of Study Figure 1. Variation in diaphragm thickness over time during the first week of mechanical ventilation. Subjects were categorized based on the magnitude and direction of change in diaphragm thickness: 47 (44%) decreased by more than 10%, 47 (44%) remained unchanged, and 13 (12%) increased by more than 10%. Mean and standard deviation are plotted for each group for each study day. Numbers shown next to each data point indicate the number of patients remaining on the ventilator in each group on each study day. Trend line and confidence intervals (shaded area) were fitted by Loess smoothing. Page 4 of 8

5 Figure 2. Diaphragm contractile activity (inspiratory effort) is associated with the rate and direction of change in diaphragm thickness during mechanical ventilation. At low contractile activity levels, diaphragm thickness declines over time (lower arrow) while at high contractile activity levels diaphragm thickness increases over time (upper arrow) (p=0.002 for effect modification). Diaphragm thickness was stable over time at levels of contractile activity that are typically observed in healthy subjects during resting tidal breathing (blue band on y-axis) (21, 37). Variation in thickness is adjusted for the effects of age, sex, baseline SAPS II score, daily SOFA score, and diagnosis of sepsis. Page 5 of 8

6 Basic Science Human Mesenchymal Stem/Stromal Cells (MSCs) recruit monocytes to the infection injured lung via a CCR2 dependent mechanism. Hogan G 1, Masterson C 1, Jerkic M 1, Laffey JG 1,2, Curley GF 1,2 1 Departent of Anesthesia, Keenan Research Centre for Biomedical Science of St Michael s Hospital, St. Michael's Hospital, Toronto; 2 Department of Anesthesia, University of Toronto Introduction: ARDS is a complex and debilitating syndrome which is characterized by acute respiratory failure. Despite intensive research, a therapy for ARDS remains elusive and current strategies are purely supportive. As a result, mortality remains high and there is urgent need for an effective treatment. Human bone marrow MSCs (hbm-mscs) have shown considerable promise in pre-clinical studies of ARDS. MSCs modulate the immune response to reduce lung injury, and enhance the clearance of bacteria, in murine and rodent Escherichia coli pneumonia, and in the isolated human lung. The mechanisms by which MSCs exert beneficial effects are complex, and include their ability to modulate macrophage phenotype and function. We wished to establish an Escherichia coli pneumonia model of ARDS in the rat and to determine the potential of hbm-mscs to recruit monocytes to the injued lung in vivo and in vitro. Methods: Adult male Sprague Dawley rats were anesthetized and received E.coli bacteria intratracheally. In all experiments, the animals were sacrificed at 48 hours post-instillation and physiological markers of ARDS were assessed. Once satisfied with the model, a series of animals were randomised to intravenous administration 4 hours post-instillation of: (1) vehicle (PBS, 800μl; n=12); or (2) 1x10 7 hbm-mscs/kg (n=16). In vitro experiments were carried out in parallel to investigate the role of hbm-mscs in monocyte chemotaxis and their effect on inflammatory cytokine levels. Results: We successfully established a rodent model of sepsis-induced ARDS, with animals displaying (i) decreased lung compliance, (ii) impaired oxygenation, and (iii) increased alveolar cellular infiltration. Furthermore, hbm-mscs improved E.coli pneumonia associated acute lung injury. All rats in the cell-treated group survived compared to 25% mortality in the vehicle group. Although the results did not reach significance, there was a trend in support of the hbm-msc group for improved lung compliance and oxygenation. hbm-mscs decreased immune cell infiltration in the lung, particularly neutrophil infiltration which is a key hallmark of ARDS. In vitro ELISA analysis showed significantly lower levels of the pro-inflammatory cytokine TNF-α in rats who received hbm-mscs compared to the non-cell-treated group. Finally, hbm-mscs increased monocyte chemotaxis alone, and to a further degree when pre-activated with LPS, an effect which was reduced by inhibition of CCR2 on monocytes. Conclusions: hbm-msc therapy demonstrates potential in the treatment of sepsis-induced ARDS, with an ever increasing body of evidence both in vivo and in vitro. This study identifies a potentially important therapeutic effect of MSCs monocyte recruitment to the infection injured lung. Page 6 of 8

7 Clinical Research Dexmedetomidine Reduces Delirium After Cardiac Surgery: A Randomized Controlled Trial. Silverton N, Katznelson R, Carroll J, Styra R, Rao V, Fedorko L, Djaiani G. Background: Approximately one in five elderly patients experience postoperative delirium (POD) after cardiac surgery. 1 POD is associated with higher mortality, longer hospital length of stay (LOS), and increased health care costs. 2-4 Dexmedetomidine (DEX) is an α2-adrenergic receptor agonist that possesses sedative and analgesic properties, whilst lacking clinically significant anticholinergic effects, and respiratory depression. The current study is a prospective, randomized, controlled clinical trial comparing DEX and propofol (PROP) based postoperative sedation regimens after high-risk cardiac surgery. We hypothesized that DEX based approach would result in lower POD rates after surgery. Methods: After Institutional Ethics Review Board approval, an informed consent was acquired in patients over 60 years of age undergoing elective complex cardiac surgery, and over 70 years of age undergoing either isolated coronary revascularization, or single valve repair/replacement surgery. Patients with a history of psychiatric disease, delirium, severe dementia, or undergoing emergency procedures were excluded. Anesthesia, monitoring, and surgical techniques were conducted according to routine institutional practice. Upon arrival to intensive care unit (ICU), patients received either DEX bolus of 0.4 g/kg followed by an infusion of g/kg/h, or PROP infusion g/kg/min. DEX infusion was continued for a maximum period of 24 hours. Assessment of delirium was performed with confusion assessment method (CAM) for ICU preoperatively (baseline) and postoperatively every 12 hours or as needed according to the patient s condition during the first 5 postoperative days. Patients were rendered either CAM-positive (delirium present) or CAM-negative (delirium absent). Given the prevalence of delirium of 20% in patients over 60 years of age, 1 to see a reduction to 6% (3% in low risk patients 5 ), with = 0.05 and 1- = 0.8, the group of 90 patients in each arm of the study is required for a total of 180 patients. Delirium rate was calculated with the 2 test for differences in probabilities of a 2x2 contingency table. All analyses were performed on an intention-to-treat basis. Results: POD was present in 16 of 91 (17.5%; 95% CI, 9.7 to 25.3), and 29 of 92 (31.5%; 95% CI, 22.0 to 41.0) patients in the DEX and PROP groups respectively, p = Median duration of delirium was 2 [1-4] vs 3 [1-5] days in DEX and PROP groups, p = Both groups were similar with respect to demographic data, preoperative medications, co-morbidities, and surgical characteristics. In patients who had delirium, the median difference in ICU- and hospital-los was 8.7hours and 2.5days favouring the DEX group.(table) Conclusions: Postoperative administration of DEX based sedation regimen in elderly patients resulted in lower POD rates after high-risk cardiac surgery. References: 1. Katznelson R, Djaiani G, Borger M, Friedman Z, Abbey S, Fedorko L, Karski J, Mitsakakis N, Carroll J, Beattie WS. Preoperative Use of Statins Is Associated with Reduced Early Delirium Rates after Cardiac Surgery. Anesthesiology 2009; 0:67 73 Page 7 of 8

8 2. Rudolph JL, Babikian VL, Birjiniuk V, Crittenden MD, Treanor PR, Pochay VE, Khuri SF, Marcantonio ER: Atherosclerosis is associated with delirium after coronary artery bypass graft surgery. J Am Geriatr Soc 2005; 53: Milbrandt EB, Deppen S, Harrison PL, Shintani AK, Speroff T, Stiles RA, Truman B, Bernard GR, Dittus RS, Ely EW: Costs associated with delirium in mechanically ventilated patients. Crit Care Med 2004; 32: Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE Jr, Inouye SK, Bernard GR, Dittus RS: Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291: Maldonado JR, Wysong A, van der Starre PJ, Block T, Miller C, Reitz BA. Dexmedetomidine and the reduction of postoperative delirium after cardiac surgery. Psychosomatics. 2009; 50: Page 8 of 8