Article 1
Early metabolic support for critically ill trauma patients: A prospective randomized controlled trial. Stolarski AE, Lorraine Y, Weinberg J, Kim J, Lusczek E, Remick DG, Bistrian B, Burke P. Journal of Trauma and Acute Care Surgery. 2022 Feb 1;92(2):255-265.
Nutritional support is a fundamental aspect of ICU management, but practice patterns often vary significantly with little evidence base. It is well-known that early enteral feeds are crucial for a variety of reasons, but obstacles include frequent interventions and procedures or feeding intolerance leading to suboptimal nutritional intake. The authors of this study investigated the effects of early parenteral amino acid infusion on observed differences in metabolomic profiles. In this open label, randomized controlled trial, subjects in the early metabolic support (EMS) group received an IV solution with 27g of dextrose and 65g of a mixed standard parenteral amino acid solution. The infusion was titrated to provide the patient with 1.5 to 2.0 grams of protein/kg per day. Enteral feeds were initiated when clinically appropriate and advanced as tolerated, as the protein solution was down titrated to maintain ~2.0g of protein/kg/day. In the standard of care group (control), enteral nutrition was initiated as soon as clinically feasible. Metabolic and cytokine profiles were assessed at baseline (within 24 hours of admission) and on day 5.
42 patients were recruited, and patient characteristics were well-balanced between groups. In the first 5 days, the EMS group received an average of 12.6kcals/kg with 122 grams of protein per day, while the control group received 7.5kcals/kg with 31 grams of protein per day. 834 biochemicals were analyzed and they found that EMS had a significant effect on 67 biochemicals over the intervention period. In the EMS group, notable changes include increased urea nitrogen excretion over 5 days, increased circulating amino acids, greater decrease in proinflammatory IL-1β, and greater increase in soluble IL-6 receptor. There was also a smaller decline in albumin over the course of the intervention. However, there was no statistically significant difference in median hospital LOS or ICU LOS. The investigators found that early metabolic support was not harmful and substantially improved many aspects of metabolism and inflammation. This intervention may allow intensivists to improve the metabolic profiles of our critically ill trauma patients and should be further studied with larger randomized controlled trials.
Article 2
Multiple Organ Dysfunction in Older Major Trauma Critical Care Patients. Cole E, Aylwin C, Christie R, Dillane B, Farrah H, Hopkins P, Ryan C, Woodgate A, Brohi K. Annals of Surgery Open. 2022 Jun;3(2):e174.
It is quite evident that the care of elderly trauma patients can be challenging and complex. For numerous reasons, their recovery is often complicated by many factors, such multiple organ dysfunction syndrome (MODS). While age has historically been linked to MODS in trauma patients, more recently its association has been less robust, and chronological age may be less predictive of MODS and other poor outcomes. Preinjury frailty, however, predicts in-hospital mortality in trauma patients and may be more strongly linked to severe organ dysfunction than age. Investigators of this study aimed to identify characteristics of older trauma patients who developed MODS, compared to younger patients. Four major trauma centers in London enrolled consecutive adult trauma patients requiring admission to the ICU. Preinjury frailty was screened for using the 5-point British Geriatric Society “Recognising frailty syndromes” guidance, with a confirmatory Edmonton Frail Scale assessment.
1316 patients were enrolled in the study, of which 434 were older than 65 years. Older patients were more likely to be female, have sustained a blunt injury, and to be frail (49% vs 5%). Overall mortality was higher in the older group (28% vs 12%). There was no significant difference in the incidence of MODS between patients over 65 years and patients under 65 years (70% vs 64%). As expected, mortality was higher in elderly MODS patients (36%) compared to younger MODS patients (19%) or elderly patients without MODS (10%). In this study, frailty was most strongly associated with the development of MODS in older patients (adjusted OR 6.96); however, it was not related to the time to MODS recovery. TBI was also strongly linked to MODS mortality in the elderly trauma patient (OR 2.05). Other factors associated with the development of MODS were injury severity, admission shock, and crystalloid volume administered within the first 24 hours.
This prospective multicenter study of major trauma ICU patients established a strong link between frailty and development of MODS in the elderly. This study is limited in part by the investigators’ decision to determine frailty as a binary characteristic; it is not possible to determine from this study whether the severity of frailty correlates with organ dysfunction or mortality. The results of this study suggest that timely identification of frailty in critical care may predict outcomes and the need for interventions that target frailty during the clinical course.
Article 3
How doctors manage conflicts with families of critically ill patients during conversations about end-of-life decisions in neonatal, pediatric, and adult intensive care. Spijkers AS, Akkermans A, Smets E M.A., Schultz MJ, Cherpanath T G.V., van Woensel J, van Heerde M, van Kaam AH, van de Loo M, Willems DL, de Vos MA. Intensive Care Medicine. 2022 Jul;48(7):910-922.
Conflicts, such as disagreements, disputes, or differences in opinions between physicians and families commonly occur in the ICU setting. Unresolved conflicts lead to feelings of regret, distress, and distrust in patient families, and feelings of anxiety, moral distress, and burnout in physicians. While several studies have retrospectively investigated family-physician conflicts in the ICU setting, none have explored conflicts in real-time or introduced strategies to assist physicians in conflict mitigation. Therefore, Spijkers and colleagues conducted a prospective qualitative exploratory study where conversations between physicians and families of critically ill patients, cared for in the NICU, PICU, and adult ICU at a single large university-based hospital, were audio-recorded from the moment doubts arose whether treatment was still in patients’ best interest, until conflict resolution. The aims of the study were to identify the main topics of team-family conflicts, explore the factors further complicating conflicts, investigate the strategies physicians use to manage conflicts, establish which strategies appear to be (in)effective in managing conflicts and explore the possible differences between the three ICU settings. Transcripts were coded and analyzed using a qualitative deductive approach.
Team-family conflicts occurred in 29/101 conversations (29%) concerning 20/36 patients (56%) who participated in the study. Conflicts evolved around treatment decisions, timing of the decisions and/or decision-making conversations, patients’ current health status, patients’ future health status, decision-making responsibility, and patients’ (presumed) wishes. Four main complicating factors were identified that led to conflict escalation: diagnostic and prognostic uncertainty, families’ strong negative emotions, limited health literacy, and burden of responsibility. Four strategies were utilized by physicians to manage conflicts: content-oriented, process-oriented, moral, and empathetic strategies. The content-oriented strategy, which focused on explaining the patient’s health status, was most commonly used by physicians. Most conflicts were effectively dealt with by means of content-oriented strategies on the condition that the conflict was unambiguous and uncomplicated. In the presence of one or more of the complicating factors listed above, empathetic (acknowledging emotions, encouraging, and supporting families, listening to the family’s needs and concerns, and creating a safe environment for open dialogue) and process-oriented (postponing decision making) strategies proved to be more effective. In contrast, conflict escalation rather than resolution occurred when physicians utilized moral strategies (argumentative decisive moral statements). Overall, the empathetic strategy was the most effective strategy in conflict resolution.
This study emphasizes that conflict resolution in the ICU is not a one-size fits all model. On the contrary, successful conflict resolution is a multi-step process that requires physicians to 1) properly identify the root cause of conflict, 2) recognize whether additional complicating factors exist 3) tailor communication strategies to concrete conflict topics and to context and family related factors 4) always utilize the invaluable empathetic strategies to maximize success at conflict mediation and resolution.
Article 4
A three-step support strategy for relatives of patients dying in the intensive care unit: a cluster randomized trial. Kentish-Barnes N, Chevret S, Valade S, Jaber S, Kerhuel L, Guisset O, Martin M, Mazaud A, Papazian L, Argaud L, Demoule A, Schnell D. Lancet. Feb 12;399(10325):656-664.
While ICU care is usually focused on prolongation of life, a substantial number of ICU patients die. As a result, intensivists are tasked with the important role of supporting family members at the end of life and in bereavement. The grief experienced by family members after the death of a loved one results in long term functional impairment and health consequences. While bereavement support in the ICU setting has long been identified as a clinical and research priority, most ICUs do not offer any formal bereavement support, and few if any intensivists receive training in bereavement support. Additionally, most of the current available literature regarding bereavement consists of small, single-center studies with limited generalizability.
Kentish-Barnes and colleagues conducted an unblinded, large, multicenter, cluster randomized trial of a three-component, communication-based intervention delivered by intensivists before, during, and after the end-of-life (EOL) period, in 34 French ICUs. Family members of patients who died following a stay of 2 days or more were included in the study. Each ICU was randomly assigned to receive dedicated education about how to deliver the three-component intervention, or usual care. The intervention involved three meetings of the physicians and nurse in charge of the patient with the relatives: a family conference to prepare the relatives for the imminent death, an ICU-room visit to provide active support, and a meeting after patient’s death to offer condolences and closure. The goal in each meeting was to allow family members to express emotions, ask questions, check understanding of the medical information and be assured that care to the patient would continue until death. Attentive listening, sensitivity to non-verbal communications, and empathy were the mainstay of the meetings. In the participating control ICUs, family meetings occurred, but they did not feature a systematic exploration of multiple issues, nurses and physicians did not typically enter the room during the dying process, and there was no routine follow-up with the families following patient death. The primary end point was the proportion of relatives with prolonged grief, measured as the prolonged grief-13 (PG-13) questionnaire score ≥ 30, six months after death. Secondary endpoints included satisfaction with EOL communication evaluated at 1 month, symptoms of anxiety and depression at 1,3, and 6 months, and PTSD symptoms at 3 and 6 months.
Eight hundred and seventy-five family members participated in the study. Most of the participants were the female spouses or female children of the deceased patient. All steps of the intervention were implemented for approximately 90% of the relatives in the intervention centers. Family members who received the intervention had lower prevalence of symptoms of prolonged grief (15% vs. 21%, p=0.03), depression, anxiety, and PTSD (12% vs. 22%, p=0.005) during the follow-up period than did family members in the control group. While current ICU model in the United States includes routine EOL conferences and a physician or a nurse present during the EOL period, this novel and proactive intervention introduces an additional component that is not routinely performed by most ICUs. That is, providing support to the family after their loved one’s death. This step could prove to be beneficial for both the family and the ICU team. For families it provides an opportunity to get answers to any of their remaining questions and provides reassurance. For the ICU team this may provide closure. This study highlights the importance of and the continued need for both a patient and family centered EOL care and bereavement model to ease the grieving process for family members.
