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Objectives: Evidence linking end-of-life-care quality in ICUs to bereaved family members' psychologic distress remains limited by methodological insufficiencies of the few studies on this topic. To examine comprehensively the associations of family surrogates' severe anxiety and depressive symptoms with end-of-life-care quality in ICUs over their first 6 months of bereavement.Design: Prospective, longitudinal, observational study.Setting/participants: Family surrogates (n = 278) were consecutively recruited from seven medical ICUs at two academically affiliated medical centers in Taiwan.Measurements and Statistical Analysis: Family surrogates' anxiety and depressive symptoms were assessed 1, 3, and 6 months postloss using the Hospital Anxiety and Depression Scale. Family satisfaction with end-of-life care in ICUs was assessed 1-month postloss by the Family Satisfaction in the ICU questionnaire. Patients' end-of-life care was documented over the patient's ICU stay. Associations of severe anxiety and depressive symptoms (scores ≥ 8 for each subscale) with end-of-life-care quality in ICUs (documented by patient care received and family satisfaction with end-of-life care in ICUs) were examined by multivariate logistic regression models with generalized estimating equation.Main Results: Prevalence of severe anxiety and depressive symptoms decreased significantly over time. Surrogates' lower likelihood of severe anxiety or depressive symptoms 3-6 month postloss was associated with death without cardiopulmonary resuscitation, withdrawing life-sustaining treatments, and higher family satisfaction with end-of-life care in ICUs. Bereaved surrogates' higher likelihood of these symptoms was associated with physician-surrogate prognostic communication and conducting family meetings before patients died.Conclusions: End-of-life-care quality in ICUs is associated with bereaved surrogates' psychologic well-being. Enhancing end-of-life-care quality in ICUs by improving the process of end-of-life care, for example, promoting death without cardiopulmonary resuscitation, withdrawing life-sustaining treatments, and increasing family satisfaction with end-of-life care, can lighten bereaved family surrogates' severe anxiety symptoms and severe depressive symptoms. [ABSTRACT FROM AUTHOR]

The article presents a study on the assessment of the clinical applicability of pulse pressure variation and stroke volume variation in predicting fluid responsiveness on acute respiratory distress syndrome patients ventilated with protective strategy. It concludes that baseline pulse pressure variation accurately predicted the fluid responsiveness in early acute respiratory distress syndrome patients.

Objectives: Scarce research explores factors of concurrent psychologic distress (prolonged grief disorder [PGD], post-traumatic stress disorder [PTSD], and depression). This study models surrogates' longitudinal, heterogenous grief-related reactions and multidimensional risk factors drawing from the integrative framework of predictors for bereavement outcomes (intrapersonal, interpersonal, bereavement-related, and death-circumstance factors), emphasizing clinical modifiability., Design: Prospective cohort study., Setting: Medical ICUs of two Taiwanese medical centers., Subjects: Two hundred eighty-eight family surrogates., Interventions: None., Measurements and Main Results: Factors associated with four previously identified PGD-PTSD-depressive-symptom states (resilient, subthreshold depression-dominant, PGD-dominant, and PGD-PTSD-depression concurrent) were examined by multinomial logistic regression modeling (resilient state as reference). Intrapersonal: Prior use of mood medications correlated with the subthreshold depression-dominant state. Financial hardship and emergency department visits correlated with the PGD-PTSD-depression concurrent state. Higher anxiety symptoms correlated with the three more profound psychologic-distress states (adjusted odds ratio [95% CI] = 1.781 [1.562-2.031] to 2.768 [2.288-3.347]). Interpersonal: Better perceived social support was associated with the subthreshold depression-dominant state. Bereavement-related: Spousal loss correlated with the PGD-dominant state. Death circumstances: Provision of palliative care (8.750 [1.603-47.768]) was associated with the PGD-PTSD-depression concurrent state. Surrogate-perceived quality of patient dying and death as poor-to-uncertain (4.063 [1.531-10.784]) correlated with the subthreshold depression-dominant state, poor-to-uncertain (12.833 [1.231-133.775]), and worst (12.820 [1.806-91.013]) correlated with the PGD-PTSD-depression concurrent state. Modifiable social-worker involvement (0.004 [0.001-0.097]) and a do-not-resuscitate order issued before death (0.177 [0.032-0.978]) were negatively associated with the PGD-PTSD-depression concurrent and the subthreshold depression-dominant state, respectively. Apparent unmodifiable buffering factors included surrogates' higher educational attainment, married status, and longer time since loss., Conclusions: Surrogates' concurrent bereavement distress was positively associated with clinically modifiable factors: poor quality dying and death, higher surrogate anxiety, and palliative care-commonly provided late in the terminal-illness trajectory worldwide. Social-worker involvement and a do-not-resuscitate order appeared to mitigate risk., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and Wolters Kluwer Health, Inc.)

Objectives: To examine associations between family surrogates' bereavement outcomes and four previously determined quality of dying and death (QODD) latent classes (high, moderate, poor-to-uncertain, and worst)., Design: Prospective, longitudinal, observational study., Setting: Medical ICUs at two academically affiliated medical centers in Taiwan., Patients/participants: Three hundred nine family surrogates responsible for decision-making for critically ill patients at high risk of death (Acute Physiology and Chronic Health Evaluation II scores > 20) from a disease., Interventions: None., Measurements and Main Results: Participants were assessed by the depression and anxiety subscales of the Hospital Anxiety and Depression Scale, the Impact of Event Scale-Revised, 11 items of the Prolonged Grief Disorder (PGD) scale, and the Medical Outcomes Study 36-Item Short-Form Health Survey at 1, 3, 6, 13, 18, and 24 months post-loss. We simultaneously examined associations of four QODD latent classes with physical and mental health-related quality of life (HRQOL) and symptoms of anxiety, depression, post-traumatic stress disorder (PTSD), and PGD assessed over 24 bereavement months using multivariate hierarchical linear modeling. Surrogates' distinct QODD latent classes assessed at 1-month post-loss were significantly associated with bereavement outcomes, except for physical HRQOL and PGD symptoms. Significantly more depressive symptoms and worse mental HRQOL (β [95% CI]) were reported by bereaved surrogates in the moderate (1.958 [1.144-2.772], -2.245 [-3.961 to -0.529]), poor-to-uncertain (2.224 [1.438-3.010], -7.026 [-8.683 to -5.369]), and worst (2.081 [1.215-2.964], -4.268 [-6.096 to -2.440]) QODD classes than those in the high QODD class. Bereaved surrogates in the moderate (2.095 [1.392-2.798]) and poor-to-uncertain (0.801 [0.123-1.480]) QODD classes reported more anxiety symptoms, whereas those in the poor-to-uncertain QODD class suffered more PTSD symptoms (2.889 [1.005-4.774]) than those in the high QODD class., Conclusions: The four distinct QODD latent classes were significantly associated with ICU family surrogates' bereavement outcomes, suggesting targets to improve end-of-life care quality in ICUs., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and Wolters Kluwer Health, Inc.)

Objectives: Grief-related psychological distress often co-occurs to conjointly impair function during bereavement. Knowledge of comorbid grief-related psychological distress is limited: no longitudinal study has examined dynamic patterns of co-occurring prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression, and previous assessment time frames have been variable and potentially inadequate given the duration criterion for PGD. Therefore, the purpose of this study was to investigate the transition of distinct symptom states based on the co-occurrence of PGD, PTSD, and depression symptoms for ICU bereaved surrogates over their first two bereavement years., Design: Prospective, longitudinal, observational study., Setting: Medical ICUs at two academically affiliated medical centers in Taiwan., Patients/participants: Three hundred three family surrogates responsible for decision-making for critically ill patients at high risk of death (Acute Physiology and Chronic Evaluation II scores > 20) from a disease., Intervention: None., Measurements and Main Results: Participants were assessed by 11 items of the Prolonged Grief Disorder (PG-13) scale, the Impact of Event Scale-Revised, and the depression subscale of the Hospital Anxiety and Depression Scale at 6, 13, 18, and 24 months postloss. PGD-PTSD-depression-symptom states and their evolution were examined by latent transition analysis. The following four distinct PGD-PTSD-depression-symptom states (prevalence) were initially identified: resilient (62.3%), subthreshold depression-dominant (19.9%), PGD-dominant (12.9%), and PGD-PTSD-depression comorbid (4.9%) states. These PGD-PTSD-depression-symptom states remained highly stable during the first two bereavement years, with transitions predominantly toward resilience. Prevalence for each state at 24 months postloss was 82.1%, 11.4%, 4.0%, and 2.5%, respectively., Conclusions: Four highly stable PGD-PTSD-depression-symptom states were identified, highlighting the importance of screening for subgroups of ICU bereaved surrogates with increased PGD or comorbid PGD, PTSD, and depression symptoms during early bereavement., Competing Interests: Drs. Wen and Chuang disclosed work for hire. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a useful life support in severe acute respiratory distress syndrome (ARDS). Although prolonged mechanical ventilation (MV) before institution of ECMO is known to be a poor prognostic factor for outcomes of VV-ECMO, a reasonable deadline for this period has not been defined yet. To discover the answer, we reviewed a 9 year institutional experience of adult respiratory ECMO in VV configuration and investigate the relationship between the MV time before ECMO and in-hospital mortality. This retrospective study included 129 adult patients receiving VV-ECMO for ARDS in a single institution from 2007 to 2016. Important demographic and clinical data before ECMO intervention were collected for analyses of in-hospital mortality. The MV time before ECMO independently predicted hospital death in adult respiratory ECMO here. While compared to the patients receiving MV for 7 days or less, the patients receiving MV for more than 7 days before ECMO showed a higher in-hospital mortality rate (77% vs. 38%, p < 0.001). They also experienced a more significant deterioration in respiratory function during MV before the institution of ECMO. Therefore, from the clinical observation, we thought that a 7 day period might be an acceptable limit on MV time before institution of VV-ECMO. Integrating other respiratory parameters into the current PaO2/FiO2 (PF) ratio-based inclusion criteria of adult respiratory ECMO might be helpful to reduce the risk of prolonged MV in selected patients.

Background: Pneumonia is the leading risk factor of acute respiratory distress syndrome (ARDS). It is increasing studies in patients with pneumonia to reveal that coinfection with viral and bacterial infection can lead to poorer outcomes than no coinfection. This study evaluated the role of coinfection identified through bronchoalveolar lavage (BAL) examination on the outcomes of pneumonia-related ARDS., Methods: We performed a prospective observational study at Chang Gung Memorial Hospital from October 2012 to May 2015. Adult patients were included if they met the Berlin definition of ARDS. The indications for BAL were clinically suspected pneumonia-related ARDS and no definite microbial sample identified from tracheal aspirate or sputum. The presence of microbial pathogens and clinical outcomes were analyzed., Results: Of the 19,936 patients screened, 902 (4.5%) fulfilled the Berlin definition of ARDS. Of these patients, 255 (22.7%) had pneumonia-related ARDS and were included for analysis. A total of 142 (55.7%) patients were identified to have a microbial pathogen through BAL and were classified into three groups: a virus-only group (n = 41 [28.9%]), no virus group (n = 60 [42.2%]), and coinfection group (n = 41 [28.9%]). ARDS severity did not differ significantly between the groups (P = 0.43). The hospital mortality rates were 53.7% in virus-only identified group, 63.3% in no virus identified group, and 80.5% in coinfection identified group. The coinfection group had significantly higher mortality than virus-only group (80.5% vs. 53.7%; P = 0.01)., Conclusion: In patients with pneumonia-related ARDS, the BAL pathogen-positive patients had a trend of higher mortality rate than pathogen-negative patients. Coinfection with a virus and another pathogen was associated with increased hospital mortality in pneumonia-related ARDS patients.

Despite gaining popularity, venovenous extracorporeal membrane oxygenation (VV-ECMO) remains a controversial therapy for acute respiratory failure (ARF) in adult patients due to its equivocal survival benefits. The study was aimed at identifying the preinterventional prognostic predictors of hospital mortality in adult VV-ECMO patients and developing a practical mortality prediction score to facilitate clinical decision-making.This retrospective study included 116 adult patients who received VV-ECMO for severe ARF in a tertiary referral center, from 2007 to 2015. The definition of severe ARF was PaO2/ FiO2 ratio < 70 mm Hg under advanced mechanical ventilation (MV). Preinterventional variables including demographic characteristics, ventilatory parameters, and severity of organ dysfunction were collected for analysis. The prognostic predictors of hospital mortality were generated with multivariate logistic regression and transformed into a scoring system. The discriminative power on hospital mortality of the scoring system was presented as the area under receiver operating characteristic curve (AUROC).The overall hospital mortality rate was 47% (n = 54). Pre-ECMO MV day > 4 (OR: 4.71; 95% CI: 1.98-11.23; P < 0.001), pre-ECMO sequential organ failure assessment (SOFA) score >9 (OR: 3.16; 95% CI: 1.36-7.36; P = 0.01), and immunocompromised status (OR: 2.91; 95% CI: 1.07-7.89; P = 0.04) were independent predictors of hospital mortality of adult VV-ECMO. A mortality prediction score comprising of the 3 binary predictors was developed and named VV-ECMO mortality score. The total score was estimated as follows: VV-ECMO mortality score = 2 × (Pre-ECMO MV day > 4) + 1 × (Pre-ECMO SOFA score >9) + 1 × (immunocompromised status). The AUROC of VV-ECMO mortality score was 0.76 (95% CI: 0.67-0.85; P < 0.001). The corresponding hospital mortality rates to VV-ECMO mortality scores were 18% (Score 0), 35% (Score 1), 56% (Score 2), 75% (Score 3), and 88% (Score 4), respectively.Duration of MV, severity of organ dysfunction, and immunocompromised status were important preinterventional prognostic predictors for adult VV-ECMO. The 3 prognostic predictors could also constitute a practical prognosticating tool in patients requiring this advanced respiratory support. Physicians in ECMO institutions are encouraged to perform external validations of this prognosticating tool and make contributions to score optimization., Competing Interests: The authors have no funding and conflicts of interest to disclose. Competing Interests: The authors declare that they have no competing interests.

Methicillin-resistant Staphylococcus aureus (MRSA) is a common and important cause of colonization and infection in medical intensive care units (ICU). The aim of this study was to assess association factors between MRSA nasal colonization and subsequent infections in medical ICU patients by clinical investigation and molecular genotyping. A prospective cohort observational analysis of consecutive patients admitted to medical ICUs between November 2008 and May 2010 at a tertiary teaching hospital were included. To detect MRSA colonization, the specimens from the nares were obtained within 3 days of admission to the ICU and again 1 week following admission to the ICU. Genetic relatedness for colonized and clinical isolates from each study patient with MRSA infection were analyzed and compared. A total of 1266 patients were enrolled after excluding 195 patients with already present MRSA infections. Subsequent MRSA infection rates were higher in patients with nasal colonization than in those without (39.1% versus 14.7%, respectively). Multivariate Poisson regression analysis demonstrated that nasal MRSA colonization (relative risk [RR]: 2.50; 95% confidence interval [CI]: 1.90-3.27; P < 0.001) was independent predictors for subsequent MRSA infections. History of tracheostomy, however, was a protective predictor in all patients (RR: 0.38; 95% CI: 0.18-0.79; P = 0.010) and in patients with MRSA nasal colonization (RR: 0.22; 95% CI: 0.55-0.91; P = 0.037). Molecular genetics studies revealed that most MRSA isolates were healthcare-associated clones and that nasal and clinical isolates exhibited up to 75% shared identity. Methicillin-resistant S. aureus nasal colonization was significantly associated with subsequent MRSA infection among medical ICU patients. Previous MRSA infection was associated with subsequent MRSA infections, and history of tracheostomy associated with reducing this risk. Most MRSA isolates were healthcare-associated strains that were significantly correlated between nasal and clinical isolates.

Background: High-frequency oscillatory ventilation (HFOV) may be used as a rescue therapy for adults with acute respiratory distress syndrome who have failed conventional ventilation (CV). We undertook a prospective study to investigate the determinants of mortality and the sequential evolution of organ failures in HFOV-treated adult acute respiratory distress syndrome patients., Methods: The indication for HFOV was severe oxygenation failure (PaO2/FiO2 <120 mm Hg) while receiving aggressive CV support (defined by either PaO2 ≤65 mm Hg with FiO2 ≥0.6 when positive end-expiratory pressures >10 cmH2O or plateau airway pressure ≥35 cm H2O). Demographic, clinical, and physiologic data were collected prospectively (May 2007-July 2009). Organ System Failure (OSF), Sequential Organ Failure Assessment (SOFA), and Multiple Organ Dysfunction (MOD) scores were recorded during and after HFOV application. Additional outcome measures included HFOV successful weaning rate, cause of failure, complications, survival rate, and cause of death., Results: The intensive care unit mortality rate was 62% (21 of 34). Survivors had a significantly shorter CV time before HFOV than nonsurvivors (32.8 hours ± 16.7 hours vs. 47.9 hours ± 26.2 hours, p = 0.049). Survivors had significantly lower baseline lung injury scores, OSF, SOFA, and MOD scores than nonsurvivors. After HFOV, the OSF, SOFA, and MOD scores were significantly decreased for survivors, particularly from day 3 onward., Conclusions: Survivors had early improvements in OSF scores after HFOV application. Organ failure system scoring may be used for deciding on HFOV initiation and for evaluating the effects of HFOV.

Objective: Hydroxyethyl starch (HES) has greater volume expansion effect and longer intravascular persistence than crystalloids. HES also decreases microvascular permeability and capillary leakage by biophysically plugging endothelial leaks, exerting an anti-inflammatory effect, and decreasing activation of endothelial cells. The aim of our study was to determine whether medium molecular weight HES (pentastarch) resuscitation in the early stage of acute respiratory distress syndrome (ARDS) simultaneously increases cardiac output without worsening pulmonary edema and whether it attenuates pulmonary vascular permeability., Design: Prospective observational study., Setting: Twenty-bed medical intensive care unit of a tertiary medical center., Patients: Twenty patients with early-stage ARDS., Intervention: Volume expansion with a 500-mL infusion of 10% pentastarch (HES 200/0.5) at a rate of 10 mL/kg/hr., Measurements and Main Results: Baseline hemodynamics including systemic and pulmonary artery blood pressures, central venous pressure, pulmonary artery occlusion pressure, and cardiac output were obtained from an online HP Component Monitoring System and a pulmonary artery catheter. Intrathoracic blood volume (ITBV), global end-diastolic volume, extravascular lung water (EVLW), and pulmonary vascular permeability (EVLW/ITBV) were measured with a PiCCOplus monitor. Hemodynamic measurements were repeated immediately and 2, 4, and 6 hours after volume expansion. Pentastarch loading significantly increased central venous pressure, pulmonary artery occlusion pressure, pulmonary arterial pressures, and cardiac output. Pulmonary mechanics, venous admixtures, and EVLW values remained unchanged throughout the study. EVLW/ITBV significantly decreased immediately after the pentastarch infusion., Conclusions: In patients with early ARDS, pentastarch resuscitation significantly improved their hemodynamics and cardiac output without worsening pulmonary edema and pulmonary mechanics. It even attenuated pulmonary vascular permeability.

Background: Numerous studies have suggested that high-frequency oscillatory ventilation (HFOV) used as rescue therapy may improve oxygenation in acute respiratory distress syndrome (ARDS) patients. The purpose of this study is to analyze the efficacy and safety of HFOV in surgical patients with ARDS., Methods: A total of 16 surgical ARDS patients with severe oxygenation failure received HFOV, despite aggressive conventional mechanical ventilatory support. Mean airway pressure was initially set 3 to 5 cm H2O higher than that for conventional ventilation and was subsequently adjusted to maintain oxygen saturation > or = 90% and FiO2 < or =0.6. Oxygenation, ventilation, and hemodynamic parameters were measured during conventional ventilation before initiating HFOV and during HFOV support for a total of 40 hours. Other outcome measures included duration of HFOV, successful weaning rate, cause of failure, complications, survival rate, and cause of death., Results: There was a considerable increase in Pao2/FiO2 ratio after 30 minutes, and this increase was maintained after 12 hours of HFOV throughout the study. There was a significant decrease in oxygenation index after 24 hours of HFOV support. There was no significant change in blood pressure associated with initiation and administration of HFOV. The successful weaning rate from HFOV to conventional ventilation was 75%. The intensive care unit survival rate was 43.8% and hospital survival rate was 37.5%., Conclusion: High-frequency oscillatory ventilation was effective and safe in correcting oxygenation failure associated with ARDS in surgical patients. Future research is warranted to identify the suitable patients, timing, and optimal strategy for applying HFOV.