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Sleep during and after cardiothoracic intensive care and psychological health during recovery
Australian Critical Care 30 (2017) 109–135
Contents lists available at ScienceDirect
Australian Critical Care journal homepage: www.elsevier.com/locate/aucc
The 41st Australian and New Zealand Scientific meeting on Intensive Care and the 22nd Annual Paediatric and Neonatal Intensive Care Conference, Perth, Australia, October 2016
Nursing Scholarship Papers Blood flow rate and circuit life in continuous renal replacement therapy (CRRT): a randomised controlled trial (RCT) Nigel Fealy a,b,c,∗ , Leanne Aitken b,d,e , Eugene du Toit f , Ian Baldwin a,c , Serigne Lo g a
Department of Intensive Care, Austin Health, Melbourne b School of Nursing and Midwifery, Griffith University, Brisbane c School of Nursing and Midwifery, Deakin University, Melbourne d Princess Alexandra Hospital, Brisbane, Australia e City University London, London, United Kingdom f School of Medical Science, Griffith University, Gold Coast g Melanoma Institute of Australia, Sydney, Australia Winner: Nursing Scholarship Paper sponsored by
circuit (clotted) was similar for both groups (150 mls/min: 9.1 [5.5, 26] hrs vs. 10 [4.2, 17] hrs; p=0.37). Second and third circuits were also similar. 150 mls/min: 14 [8.5, 21] hrs vs. 13.8 [8.5, 16.7] hrs; p=0.44. 150 mls/min:17 [10.5, 28.5] hrs vs.16 [12,21.5] hrs; p=0.52 respectively. CRRT using 250 mls/min was not more likely to cause clotting compared to 150 mls/min (HR, 1.06 [0.63, 1.78]; p=0.36, variance of the random effect, 1.096 [0.23]). There were no differences in likelihood of clotting for: BMI, weight, vascular access type, length or site, mode of CRRT, INR or platelet count. CRRT with no use of anticoagulation was more likely to cause clotting compared to use of heparin or heparin/protamine (HR 1.61, [1.17, 2.21], p=0.002). Longer APTT was associated with a lower likelihood of circuit clotting (HR 0.98,[0.97, 0.99], p=0.002). Clotting was more probable in males (HR 1.64 [0.87, 3.08] p=0.02). Blood flow rate did not affect clotting during CRRT. Males and use of anticoagulation and APTT were more likely to affect circuit survival. http://dx.doi.org/10.1016/j.aucc.2017.02.003 Sleep during and after cardiothoracic intensive care and psychological health during recovery Nittaya Caruana a,∗ , Sharon McKinley b , Rosalind Elliott a,c , Leila Gholizadeh a a
University of Technology Sydney, NSW Deakin University, Victoria c Royal North Shore Hospital, NSW, Australia b
There is minimal evidence to inform blood flow rate (BFR) during CRRT. We aimed to assess the effect of BFR on circuit life during CRRT. A prospective RCT was conducted over one year in our tertiary ICU. Adult patients with acute kidney injury were randomised to either 150 or 250 mls/min. Circuit and patient data were collected until each circuit clotted or ceased electively. Duration data for clotted circuits are presented as median (Inter-quartile range) and compared using the log-rank test; p was set at <0.05. Circuit clotting data were analysed for repeated events using a hazards ratio (HR). One [AL1] hundred patients were randomised with 96 completing the study (150 mls/min-49; 250 mls/min-47) with 462 circuits; 245:150 mls/min and 217:250 mls/min. Median circuit life for 1st http://dx.doi.org/10.1016/S1036-7314(17)30079-6 1036-7314/
Intensive care patients and former ICU patients experience poor sleep quality. Psychological distress and diminished health-related quality of life are common among former ICU patients. Coronary artery bypass graft (CABG) surgery is the main reason for adults being admitted to ICU in Australia but the effect of on-pump vs off-pump surgery on sleep and recovery has not been reported. The aim was to assess self-reported sleep quality of CABG patients during and after ICU, psychological wellbeing, HRQOL during recovery and whether on-pump vs off-pump method of surgery affects sleep and recovery. Patients who underwent CABG surgery completed self-report questionnaires on sleep quality, psychological health and quality of life using validated instruments. Data collection occurred in ICU,
110
PAPERS AND POSTER ABSTRACTS / Australian Critical Care 30 (2017) 109–135
on the hospital ward, and two months and six months after hospital discharge. Patients (n=101) were aged (mean±SD) 66.6±11.1 years, 79% male and had a median ICU stay (IQR) of 2 (2-4) days, BMI 27.3±4.3 and on-pump surgery (75%). Poor sleep was reported by 44 (62%) patients at six months and by 12 patients (12%) at all time points. Patients who had off-pump surgery had lower posttraumatic stress symptoms (p=.02) and better physical HRQOL (p=.01). In multivariate analysis, prehospital insomnia (P=.004), and physical (p<.0005) and mental p<.0005) HRQOL were independently associated with sleep quality at six months. There was no association between onpump vs off-pump CABG surgical techniques and sleep quality at six months. Sleep quality of postoperative CABG patients was poor in ICU, in the hospital ward and up to six months. Poor sleep quality at six months was associated with prehospital insomnia, and physical and mental HRQOL at six months, but not with on-pump vs offpump surgical techniques. http://dx.doi.org/10.1016/j.aucc.2017.02.004 Asymptomatic central venous catheter related thrombosis in children: two year follow up Sophie E. Jones a,b,c,d,∗ , Fiona Newall a,b,c,d,e , Paul Monagle a,b,c , Timothy Cain f , Tania Griffiths f , Warwick Butt a,g
mortality in the cohort was 7.4%, none died from thromboembolic complications. Conclusions Asymptomatic CVC-related thrombosis is common in children in PICU, however in two years of follow up we found no evidence of thrombosis associated mortality and minimal thrombosis associated morbidity. The presence or absence of thrombus at initial screening ultrasound was not predictive for thrombus or PTS at 24 months, suggesting that routine imaging is of no value. Specific anticoagulant treatment of asymptomatic CVC-related thrombosis may also be unwarranted. http://dx.doi.org/10.1016/j.aucc.2017.02.005
Adult Critical Care Free Papers The effectiveness of nasal high flow oxygen therapy in ward patients: a prospective observational study Alison Pirret a,b,∗ , Susan Takerei a , Claire Matheson c , Meghan Kelly a , Wharewaina Strickland a , Joanne Harford a , Nicola Jepsen c , Lisa Welsh c , Chloe Allan c a
Critical Care Complex, Middlemore Hospital School of Nursing, Massey University c Physiotherapist Services, Middlemore Hospital, Auckland, New Zealand b
a
Paediatrics, The University of Melbourne Clinical Haematology, The Royal Children’s Hospital c Haematology Research, Murdoch Children’s Research Institute d Nursing, The University of Melbourne e Nursing Research f Medical Imaging g Paediatric Intensive Care Unit, The Royal Children’s Hospital, Melbourne, Australia b
Introduction Asymptomatic thrombosis associated with central venous catheters (CVCs) in children varies in incidence from 5-69%. The rate of other long term complications, such as Post Thrombotic Syndrome (PTS), from asymptomatic CVC-related thrombosis is unclear. Study Objectives This study determined the frequency of asymptomatic CVCrelated thrombosis in children and assessed the incidence and severity of PTS following CVC placement. Methods A prospective cohort study recruited children admitted to a paediatric intensive care unit (PICU) requiring a CVC in the jugular or femoral veins. Each child had a (blinded) ultrasound of the blood vessel in which the CVC was placed during their admission (Phase I). An ultrasound and a PTS assessment using two paediatric PTS tools were performed approximately 24 months following CVC placement (Phase II). Results 205 children were recruited. Ultrasounds of 146 children at Phase I determined a 22.6% incidence of CVC-related thrombosis. Two children were symptomatic. Phase II ultrasounds of 120 children confirmed residual thrombosis in 13.3% and vessel wall thickening in 13.3%. No radiological thrombosis extension or clinical embolization (including paradoxical emboli) occurred in the 126 children assessed at Phase II. A single sign or symptom of PTS was reported in 10 children. Clinically significant PTS was reported in 3 children, however none had functional impairment. The overall
Winner: Best Nursing Free Paper sponsored by
Whilst research demonstrates the benefits of nasal high flow (NHF) oxygen therapy in the critical care setting, limited literature exists on its benefits in ward patients. Using a prospective observational research design, we evaluated the use of NHF in adult ward patients with respiratory failure. Primary outcome was an improvement in pulmonary function as indicated by decreases in respiratory and heart rates and increases in the SpO2 and SpO2 /FiO2 ratio. The study was approved by the hospital research office. Between May and July 2015, data of 68 patients and 70 NHF episodes were collected and analysed. The median age was 71.00 years (IQR=22.00) and the mean number of comorbidities was 3.07 (95% CI: 2.61-3.54); most patients were medical specialty patients (n=47, 69.1%). Community acquired pneumonia was the most common cause of respiratory failure (n=24, 34.3%). The therapy was mostly prescribed by the patient at risk team (PART) (n=30, 42.9%) and physiotherapists (n=30, 42.9%); patients who were prescribed NHF by these groups were demographically similar. After commencing NHF, respiratory (t=2.79, p=<0.01) and heart (t=2.12, p=0.04) rates decreased and SpO2 increased (z=-3.98, p=<0.001); dyspnoea did not significantly decrease (2 =7.33, p=0.06). Over the next two days the respiratory rate continued to decrease (F=6.70, p=0.001) and the SpO2 /FiO2 ratio increase (F=5.38, p=<0.01); heart rate (F=1.32, p=0.29) and SpO2 (2 =0.69, p=0.88) remained stable. Although these improvements were seen in the total group, between-group comparisons identified significant improvements in pulmonary function were only seen in patients who had NHF prescribed by the PART. Clinical improvement was the most common reason for discontinuing NHF (n=46, 65.7%) and most patients
Contents lists available at ScienceDirect
Australian Critical Care journal homepage: www.elsevier.com/locate/aucc
The 41st Australian and New Zealand Scientific meeting on Intensive Care and the 22nd Annual Paediatric and Neonatal Intensive Care Conference, Perth, Australia, October 2016
Nursing Scholarship Papers Blood flow rate and circuit life in continuous renal replacement therapy (CRRT): a randomised controlled trial (RCT) Nigel Fealy a,b,c,∗ , Leanne Aitken b,d,e , Eugene du Toit f , Ian Baldwin a,c , Serigne Lo g a
Department of Intensive Care, Austin Health, Melbourne b School of Nursing and Midwifery, Griffith University, Brisbane c School of Nursing and Midwifery, Deakin University, Melbourne d Princess Alexandra Hospital, Brisbane, Australia e City University London, London, United Kingdom f School of Medical Science, Griffith University, Gold Coast g Melanoma Institute of Australia, Sydney, Australia Winner: Nursing Scholarship Paper sponsored by
circuit (clotted) was similar for both groups (150 mls/min: 9.1 [5.5, 26] hrs vs. 10 [4.2, 17] hrs; p=0.37). Second and third circuits were also similar. 150 mls/min: 14 [8.5, 21] hrs vs. 13.8 [8.5, 16.7] hrs; p=0.44. 150 mls/min:17 [10.5, 28.5] hrs vs.16 [12,21.5] hrs; p=0.52 respectively. CRRT using 250 mls/min was not more likely to cause clotting compared to 150 mls/min (HR, 1.06 [0.63, 1.78]; p=0.36, variance of the random effect, 1.096 [0.23]). There were no differences in likelihood of clotting for: BMI, weight, vascular access type, length or site, mode of CRRT, INR or platelet count. CRRT with no use of anticoagulation was more likely to cause clotting compared to use of heparin or heparin/protamine (HR 1.61, [1.17, 2.21], p=0.002). Longer APTT was associated with a lower likelihood of circuit clotting (HR 0.98,[0.97, 0.99], p=0.002). Clotting was more probable in males (HR 1.64 [0.87, 3.08] p=0.02). Blood flow rate did not affect clotting during CRRT. Males and use of anticoagulation and APTT were more likely to affect circuit survival. http://dx.doi.org/10.1016/j.aucc.2017.02.003 Sleep during and after cardiothoracic intensive care and psychological health during recovery Nittaya Caruana a,∗ , Sharon McKinley b , Rosalind Elliott a,c , Leila Gholizadeh a a
University of Technology Sydney, NSW Deakin University, Victoria c Royal North Shore Hospital, NSW, Australia b
There is minimal evidence to inform blood flow rate (BFR) during CRRT. We aimed to assess the effect of BFR on circuit life during CRRT. A prospective RCT was conducted over one year in our tertiary ICU. Adult patients with acute kidney injury were randomised to either 150 or 250 mls/min. Circuit and patient data were collected until each circuit clotted or ceased electively. Duration data for clotted circuits are presented as median (Inter-quartile range) and compared using the log-rank test; p was set at <0.05. Circuit clotting data were analysed for repeated events using a hazards ratio (HR). One [AL1] hundred patients were randomised with 96 completing the study (150 mls/min-49; 250 mls/min-47) with 462 circuits; 245:150 mls/min and 217:250 mls/min. Median circuit life for 1st http://dx.doi.org/10.1016/S1036-7314(17)30079-6 1036-7314/
Intensive care patients and former ICU patients experience poor sleep quality. Psychological distress and diminished health-related quality of life are common among former ICU patients. Coronary artery bypass graft (CABG) surgery is the main reason for adults being admitted to ICU in Australia but the effect of on-pump vs off-pump surgery on sleep and recovery has not been reported. The aim was to assess self-reported sleep quality of CABG patients during and after ICU, psychological wellbeing, HRQOL during recovery and whether on-pump vs off-pump method of surgery affects sleep and recovery. Patients who underwent CABG surgery completed self-report questionnaires on sleep quality, psychological health and quality of life using validated instruments. Data collection occurred in ICU,
110
PAPERS AND POSTER ABSTRACTS / Australian Critical Care 30 (2017) 109–135
on the hospital ward, and two months and six months after hospital discharge. Patients (n=101) were aged (mean±SD) 66.6±11.1 years, 79% male and had a median ICU stay (IQR) of 2 (2-4) days, BMI 27.3±4.3 and on-pump surgery (75%). Poor sleep was reported by 44 (62%) patients at six months and by 12 patients (12%) at all time points. Patients who had off-pump surgery had lower posttraumatic stress symptoms (p=.02) and better physical HRQOL (p=.01). In multivariate analysis, prehospital insomnia (P=.004), and physical (p<.0005) and mental p<.0005) HRQOL were independently associated with sleep quality at six months. There was no association between onpump vs off-pump CABG surgical techniques and sleep quality at six months. Sleep quality of postoperative CABG patients was poor in ICU, in the hospital ward and up to six months. Poor sleep quality at six months was associated with prehospital insomnia, and physical and mental HRQOL at six months, but not with on-pump vs offpump surgical techniques. http://dx.doi.org/10.1016/j.aucc.2017.02.004 Asymptomatic central venous catheter related thrombosis in children: two year follow up Sophie E. Jones a,b,c,d,∗ , Fiona Newall a,b,c,d,e , Paul Monagle a,b,c , Timothy Cain f , Tania Griffiths f , Warwick Butt a,g
mortality in the cohort was 7.4%, none died from thromboembolic complications. Conclusions Asymptomatic CVC-related thrombosis is common in children in PICU, however in two years of follow up we found no evidence of thrombosis associated mortality and minimal thrombosis associated morbidity. The presence or absence of thrombus at initial screening ultrasound was not predictive for thrombus or PTS at 24 months, suggesting that routine imaging is of no value. Specific anticoagulant treatment of asymptomatic CVC-related thrombosis may also be unwarranted. http://dx.doi.org/10.1016/j.aucc.2017.02.005
Adult Critical Care Free Papers The effectiveness of nasal high flow oxygen therapy in ward patients: a prospective observational study Alison Pirret a,b,∗ , Susan Takerei a , Claire Matheson c , Meghan Kelly a , Wharewaina Strickland a , Joanne Harford a , Nicola Jepsen c , Lisa Welsh c , Chloe Allan c a
Critical Care Complex, Middlemore Hospital School of Nursing, Massey University c Physiotherapist Services, Middlemore Hospital, Auckland, New Zealand b
a
Paediatrics, The University of Melbourne Clinical Haematology, The Royal Children’s Hospital c Haematology Research, Murdoch Children’s Research Institute d Nursing, The University of Melbourne e Nursing Research f Medical Imaging g Paediatric Intensive Care Unit, The Royal Children’s Hospital, Melbourne, Australia b
Introduction Asymptomatic thrombosis associated with central venous catheters (CVCs) in children varies in incidence from 5-69%. The rate of other long term complications, such as Post Thrombotic Syndrome (PTS), from asymptomatic CVC-related thrombosis is unclear. Study Objectives This study determined the frequency of asymptomatic CVCrelated thrombosis in children and assessed the incidence and severity of PTS following CVC placement. Methods A prospective cohort study recruited children admitted to a paediatric intensive care unit (PICU) requiring a CVC in the jugular or femoral veins. Each child had a (blinded) ultrasound of the blood vessel in which the CVC was placed during their admission (Phase I). An ultrasound and a PTS assessment using two paediatric PTS tools were performed approximately 24 months following CVC placement (Phase II). Results 205 children were recruited. Ultrasounds of 146 children at Phase I determined a 22.6% incidence of CVC-related thrombosis. Two children were symptomatic. Phase II ultrasounds of 120 children confirmed residual thrombosis in 13.3% and vessel wall thickening in 13.3%. No radiological thrombosis extension or clinical embolization (including paradoxical emboli) occurred in the 126 children assessed at Phase II. A single sign or symptom of PTS was reported in 10 children. Clinically significant PTS was reported in 3 children, however none had functional impairment. The overall
Winner: Best Nursing Free Paper sponsored by
Whilst research demonstrates the benefits of nasal high flow (NHF) oxygen therapy in the critical care setting, limited literature exists on its benefits in ward patients. Using a prospective observational research design, we evaluated the use of NHF in adult ward patients with respiratory failure. Primary outcome was an improvement in pulmonary function as indicated by decreases in respiratory and heart rates and increases in the SpO2 and SpO2 /FiO2 ratio. The study was approved by the hospital research office. Between May and July 2015, data of 68 patients and 70 NHF episodes were collected and analysed. The median age was 71.00 years (IQR=22.00) and the mean number of comorbidities was 3.07 (95% CI: 2.61-3.54); most patients were medical specialty patients (n=47, 69.1%). Community acquired pneumonia was the most common cause of respiratory failure (n=24, 34.3%). The therapy was mostly prescribed by the patient at risk team (PART) (n=30, 42.9%) and physiotherapists (n=30, 42.9%); patients who were prescribed NHF by these groups were demographically similar. After commencing NHF, respiratory (t=2.79, p=<0.01) and heart (t=2.12, p=0.04) rates decreased and SpO2 increased (z=-3.98, p=<0.001); dyspnoea did not significantly decrease (2 =7.33, p=0.06). Over the next two days the respiratory rate continued to decrease (F=6.70, p=0.001) and the SpO2 /FiO2 ratio increase (F=5.38, p=<0.01); heart rate (F=1.32, p=0.29) and SpO2 (2 =0.69, p=0.88) remained stable. Although these improvements were seen in the total group, between-group comparisons identified significant improvements in pulmonary function were only seen in patients who had NHF prescribed by the PART. Clinical improvement was the most common reason for discontinuing NHF (n=46, 65.7%) and most patients