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peer-reviewed Background: Current guidelines for the provision of protein for critically ill patients are based on incomplete evidence, due to limited data from randomised controlled trials. The present pilot randomised controlled trial is part of a program of work to expand knowledge about the clinical effects of protein delivery to critically ill patients. The primary aim of this pilot study is to determine whether an enteral feeding protocol using a volume target, with additional protein supplementation, delivers a greater amount of protein and energy to mechanically ventilated critically ill patients than a standard nutrition protocol. The secondary aims are to evaluate the potential effects of this feeding strategy on muscle mass and other patient-centred outcomes. Methods: This prospective, single-centred, pilot, randomised control trial will include 60 participants who are mechanically ventilated and can be enterally fed. Following informed consent, the participants receiving enteral nutrition in the intensive care unit (ICU) will be allocated using a randomisation algorithm in a 1:1 ratio to the intervention (high-protein daily volume-based feeding protocol, providing 25 kcal/kg and 1.5 g/kg protein) or standard care (hourly rate-based feeding protocol providing 25 kcal/kg and 1 g/kg protein). The co-primary outcomes are the average daily protein and energy delivered to the end of day 15 following randomisation. The secondary outcomes include change in quadriceps muscle layer thickness (QMLT) from baseline (prior to randomisation) to ICU discharge and other nutritional and patient-centred outcomes. Discussion: This trial aims to examine whether a volume-based feeding protocol with supplemental protein increases protein and energy delivery. The potential effect of such increases on muscle mass loss will be explored. These outcomes will assist in formulating larger randomised control trials to assess mortality and morbidity. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN: 12615000876594 UTN: U1111-1172-8563.

Critical illness causes substantial muscle loss that adversely impacts recovery and health-related quality of life. Treatments are therefore needed that reduce mortality and/or improve the quality of survivorship. The purpose of this Review is to describe both patient-centered and surrogate outcomes that quantify responses to nutrition therapy in critically ill patients. The use of these outcomes in randomized clinical trials will be described and the strengths and limitations of these outcomes detailed. Outcomes used to quantify the response of nutrition therapy must have a plausible mechanistic relationship to nutrition therapy and either be an accepted measure for the quality of survivorship or highly likely to lead to improvements in survivorship. This Review identified that previous trials have utilized diverse outcomes. The variety of outcomes observed is probably due to a lack of consensus as to the most appropriate surrogate outcomes to quantify response to nutrition therapy during research or clinical practice. Recent studies have used, with some success, measures of muscle mass to evaluate and monitor nutrition interventions administered to critically ill patients.

This document provides an update to the recommendations for physiotherapy management for adults with coronavirus disease 2019 (COVID-19) in the acute hospital setting. It includes: physiotherapy workforce planning and preparation; a screening tool for determining requirement for physiotherapy; and recommendations for the use of physiotherapy treatments and personal protective equipment. New advice and recommendations are provided on: workload management; staff health, including vaccination; providing clinical education; personal protective equipment; interventions, including awake proning, mobilisation and rehabilitation in patients with hypoxaemia. Additionally, recommendations for recovery after COVID-19 have been added, including roles that physiotherapy can offer in the management of post-COVID syndrome. The updated guidelines are intended for use by physiotherapists and other relevant stakeholders caring for adult patients with confirmed or suspected COVID-19 in the acute care setting and beyond. ispartof: JOURNAL OF PHYSIOTHERAPY vol:68 issue:1 pages:8-25 ispartof: location:Netherlands status: published

Aim Major chest trauma is associated with significant morbidity and mortality. Management of patients with major chest trauma includes pain relief, ventilatory management, surgical fixation and early rehabilitation to improve both short- and long-term outcomes. Physiotherapy is widely considered an integral component of the multidisciplinary trauma team and aims to improve respiratory status and reduce the sequelae associated with immobility and reduced physical function. Despite this there is scarce evidence describing or investigating physiotherapy interventions and how these practices vary worldwide. The aim of this study was to ascertain the current physiotherapy management of patients having sustained major chest trauma and to investigate how such practices varied internationally. Methods A purpose designed online survey was administered to a group of experienced physiotherapists who work in the field of trauma. Results Response rate was 51% ( n = 49) and respondents represented all five continents. Respondents reported focussing on active coughing ( n = 46, 96%, r = 0.5, p = 0.98), body positioning ( n = 43, 94%, r = 0.7, p = 0.41), deep breathing exercises ( n = 44, 94%, r = 0.8, p = 0.66) and early mobilisation ( n = 47, 98%, r = 1, p = 0.64). Ambulation in hospital was reported to be common ( n = 46, 98%, r = 0.2, p = 0.99) but rehabilitation to address longer term sequelae following hospital discharge was reported to be rare ( n = 4, 8%). Conclusion This survey has highlighted those practices used by physiotherapists worldwide which aim to address the complications associated with major chest trauma. Having established global practice, the study provides a platform for future research investigating the efficacy of such interventions in improving both short- and long-term outcomes for patients following major chest injury.

Introduction: There is limited qualitative enquiry from the patient perspective on the challenges of ICU recovery. Aims: To explore from the patient perspective the unmet needs following an ICU admission and strategies for follow-up support. Methods: Semi-structured 1:1 interviews with 12 participants living in the community for at least 3-months post ICU admission (median age 57 [48-64] years; 42% male; 50% surgical, 33% medical and 17% trauma). Interviews were audio-recorded, transcribed and independently crosschecked by a second researcher. Data were analysed using thematic analysis. Results: Main challenges included: physical impairments (severe fatigue, weakness, and reduced ability to perform daily activities due to low energy); mental impairments (low mood/motivation, anxiety, vulnerability due to loss of independence) and lack of empowerment (limited knowledge/uncertainty surrounding recovery expectations). Most participants reported feeling neglected/forgotten by the healthcare system and a prolonged struggle to recover on their own. 92% had a significant fear of falling with self-identified changes to walking and daily activities including: avoidance of busy environments and/or adoption of energy conservation techniques to minimise fatigue. Patient recommendations for follow up included: access to physiotherapy/psychology support either in-person or via telephone; patient empowerment through knowledge of how to exercise safely; promote adherence and motivation to exercise by engaging family or use of activity devices. Conclusion: Key potential modifiable targets have been identified which may provide future direction for the field in this area.

BACKGROUND The potential for bioimpedance spectroscopy (BIS) to identify muscle weakness and functional limitations in critical illness is unknown; this study aimed to determine association of BIS with strength/function and differences between 3 intensive care units (ICUs). METHODS A retrospective post hoc analysis of BIS, strength, and functional data from adults who required ≥48 hours of mechanical ventilation was conducted. Measures of body composition included the proportion (%) of total body water (TBW), fat mass (FM), and fat-free mass (FFM). The Medical Research Council sum score (MRC-ss) and Physical Function in ICU Test-Scored (PFIT-s) were used for strength and functional assessments. Nonparametric cross-sectional analyses were done at enrollment (≤48 hours of admission: site-A, site-C) and awakening from sedation (site-A, site-B). Raw impedance variables including 50-kHz phase angle (PA) and impedance ratio (IR) were available from site-A and site-B. RESULTS Participants were 135 adults (site-A n=59, site-B n=33, site-C n=44), with a median (interquartile range) age of 59 (50-69) years. At enrollment, TBW%, FM%, and FFM% were similar between site-A and site-C (P>.05); pooled data were not associated with MRC-ss at awakening or MRC-ss/PFIT-s at ICU discharge. At awakening, there was less TBW%, less FFM%, and greater FM% at site-B vs site-A (P≤.001) but no associations with MRC-ss/PFIT-s when using pooled data. Trends with pooled data of a lower PA and higher IR being associated with awakening MRC-ss were confirmed within site-B (PA ρ=0.70, P≤.001; IR ρ=-0.79, P≤.001). CONCLUSION Site-by-site data suggest that raw impedance variables might be useful for screening weakness and poor function.

Background Patients who survive critical illness frequently develop muscle weakness that can impact on quality of life; nutrition is potentially a modifiable risk factor. The present study aimed to explore the associations between cumulative energy deficits (using indirect calorimetry and estimated requirements), nutritional and functional outcomes. Methods A prospective single-centre observational study of 60 intensive care unit (ICU) patients, who were mechanically ventilated for at least 48 h, was conducted. Cumulative energy deficit was determined from artificial nutrition delivery compared to targets. Measurements included: (i) at recruitment and ICU discharge, weight, fat-free mass (bioimpedance spectroscopy) and malnutrition (Subjective Global Assessment score B/C); (ii) at awakening and ICU discharge, physical function (Physical Function in Intensive Care Test-scored) and muscle strength (Medical Research Council sum-score (MRC-SS). ICU-acquired weakness was defined as a MRC-SS score of less than 48/60. Results The median (interquartile range) cumulative energy deficit compared to the estimated targets up to ICU day 12 was 3648 (2514-5650) kcal. Adjusting for body mass index, age and severity of illness, cumulative energy deficit (per 1000 kcal) was independently associated with greater odds of ICU-acquired weakness [odds ratio (OR) = 2.1, 95% confidence interval (CI) = 1.4-3.3, P = 0.001] and malnutrition (OR = 1.9, 95% CI = 1.1-3.2, P = 0.02). In similar multivariable linear models, cumulative energy deficit was associated with reductions in fat-free mass (-1.3 kg; 95% CI = -2.4 to -0.2, P = 0.02) and physical function scores (-0.6 points; 95% CI = -0.9 to -0.3, P = 0.001). Conclusions Cumulative energy deficit from artificial nutrition support was associated with reduced functional outcomes and greater loss of fat-free mass in ventilated ICU patients.

BACKGROUND: International guidelines recommend greater protein delivery to critically ill patients than they currently receive. This pilot randomized clinical trial aimed to determine whether a volume-target enteral protocol with supplemental protein delivered greater amounts of protein and energy to critically ill patients compared with standard care. METHODS: Sixty participants received either the intervention (volume-based protocol, with protein supplementation) or standard nutrition care (hourly-rate-based protocol, without protein supplementation) in the intensive care unit (ICU). Coprimary outcomes were average daily protein and energy delivery. Secondary outcomes included change in quadriceps muscle layer thickness (QMLT, ultrasound) and malnutrition (subjective global assessment) at ICU discharge. RESULTS: Mean (SD) protein and energy delivery per day from nutrition therapy for the intervention were 1.2 (0.30) g/kg and 21 (5.2) kcal/kg compared with 0.75 (0.11) g/kg and 18 (2.7) kcal/kg for standard care. The mean difference between groups in protein and energy delivery per day was 0.45 g/kg (95% CI, 0.33-0.56; P < .001) and 2.8 kcal/kg (95% CI, 0.67-4.9, P = .01). Muscle loss (QMLT) at discharge was attenuated by 0.22 cm (95% CI, 0.06-0.38, P = .01) in patients receiving the intervention compared with standard care. The number of malnourished patients was fewer in the intervention [2 (7%) vs 8 (28%); P = .04]. Mortality and duration of admission were similar between groups. CONCLUSIONS: A high-protein volume-based protocol with protein supplementation delivered greater amounts of protein and energy. This intervention was associated with attenuation of QMLT loss and reduced prevalence of malnutrition at ICU discharge.

Background Suction via a minitracheostomy is a safe procedure, but its efficacy in facilitating sputum clearance in individuals with an acute condition has not been systematically reviewed. Objectives The aim of this study was to identify and synthesise the efficacy of the insertion of a minitracheostomy and tracheal suction via minitracheostomy for sputum clearance in adults who have undergone surgery or have an acute condition characterised by sputum retention. Data sources A systematic literature search using the electronic databases MEDLINE, CINAHL, EMBASE, Cochrane Library and PEDro, with searches limited to English language journal articles published between 1984 and September 2011. Data extraction and data synthesis All study designs were included. Two independent reviewers used pre-defined inclusion and exclusion criteria to identify all eligible articles. Results Six studies in six patient groups met the inclusion criteria, with two randomised controlled trials and four case series included. These studies presented the results of 278 patients following surgery and 13 with acute medical conditions. There were a range of criteria that defined the efficacy of minitracheostomy for sputum retention. Studies reporting the adjunctive role found a reduced incidence of complications associated with sputum retention following thoracic surgery. Other studies reported limited benefit in overall respiratory status with minitracheostomy. Heterogeneity among the studies was evident, with major limitations identified. Conclusions Limited evidence suggests that minitracheostomy may be a useful adjunct in optimising sputum clearance in adults following thoracic surgery, but the effects in adults with an acute condition and other types of surgery are inconclusive.

Purpose Primary aims were: (1) objectively quantify levels of physical activity with the sensewear armband mini-fly motion sensor (SWA-MF), (2) evaluate the correlation of SWA-MF measurement of active and resting energy expenditure against the ICU Mobility scale (IMS) and indirect calorimetry respectively. Materials and methods Adults mechanically ventilated ≥ 48 h and anticipated to remain in ICU ≥ 5 days were included. Physical activity (PA) was measured using a SWA-MF (over the first five days); energy expenditure was measured with both the SWA-MF and the Deltatrac II metabolic cart on day three; highest level of mobility was assessed on the IMS. Results Fifty-five participants performed median [IQR] 16.8 [0.6–152.4] minutes of PA per day (defined as > 1.0 metabolic equivalent). A strong correlation between active energy expenditure and highest level of mobility (IMS), r = 0.76, p = 0.00 was observed on day 5. The SWA-MF demonstrated moderate to good agreement with the Deltatrac II metabolic cart (n = 20), intra-class correlation co-efficient = 0.71 (p = 0.00) for the measurement of energy expenditure on day 3. Conclusions Participants demonstrated low levels of PA. Motion sensors may be a promising non-invasive measure of energy expenditure and further investigation is warranted.

To identify measures used to evaluate the broad constructs of functional impairment and limitations in the critically ill across the continuum of recovery, and to evaluate, synthesise and compare the clinimetric properties of the measures identified.A systematic review of articles was carried out using the databases Medline (1950-2014), CINAHL (1982-2014), EMBASE (1980-2014), Cochrane Library (2014) and Scopus (1960-2014). Additional studies were identified by searching personal files. Eligibility criteria for selection: Search 1: studies which assessed muscle mass, strength or function using objective non-laboratory measures; Search 2: studies which evaluated a clinimetric property (reliability, measurement error, validity or responsiveness) for one of the measures identified in search one. Two independent reviewers assessed articles for inclusion and assessed risk of bias using the consensus-based standards for selection of health status measurement instruments checklist.Thirty-three measures were identified; however, only 20 had established clinimetric properties. Ultrasonography, dynamometry, physical function in intensive care test scored and the Chelsea critical care physical assessment tool performed the strongest for the measurement of impairment of body systems (muscle mass and strength) and activity limitations (physical function), respectively.There is considerable variability in the type of measures utilized to measure physical impairments and limitations in survivors of critical illness. Future work should identify a core set of standardized measures, which can be utilized across the continuum of critical illness recovery embedded within the International Classification of Functioning framework. This will enable improved comparisons between future studies, which in turn will assist in identifying the most effective treatment strategies to ameliorate the devastating longer-term outcomes of a critical illness.

intra-hospital transport. The study was approved by the hospital ethics committee. Results: 143 patients (99M/44F, mean age 53.5 years, median APACHE-II 20.5) contributed to 263 transport events during the study. 120 transports occurredprior to and143 transports occurred post introduction of the checklist. Seven in the first and nine transports in the second group did not meet the inclusion criteria. There were no significant differences in baseline characteristics among thepre (n=113)andpost-checklist (n=134)groups. 72.4%of checklists had physiological and equipment sections completed but only 60.4% of checklists were completed fully. Transport with any physiological derangement was significantly reduced (73.2% vs 39.6%, p

Objectives: To explore the differences in patients with hepatic and gastrointestinal disease receiving PCC and/or FFP during bleeding episodes or in surgery. Methods: A single-centre retrospective observational cohort study of patients with severe coagulopathy or active bleeding in a university hospital. Results: We studied 40 patients receiving FFP only (18, 45%), PCC only (7, 17.5%) or both (15, 37.5%) during a hospital admission; their median age was 55 (46.5–63) years and 35% of patients were female. 40% of patients developed a composite outcome of death in hospital or thromboembolic complication. Compared to those receiving FFP alone, patients receiving PCC with FFP or only PCC were significantly more likely to develop the composite outcome (OR=12, 95% CI: 1.99–72.35, p=0.007 and OR=20, 95% CI: 2.21–180.9, p=0.008 respectively). The reason for admission to ICU (p=0.06) and the need for CRRT (p=0.074) were included in multivariate logistic regression analysis. Compared to those receiving FFP alone, PCC administration with or without FFP remained an independent predictor of outcome (OR=10.5, 95% CI: 1.43–76.93, p=0.021 and OR=18.21, 95% CI: 1.54–215.13, p=0.021), while admission to ICU for liver pathology or intervention appeared to be protective (OR=0.12, 95% CI: 0.02–0.91, p=0.041). Conclusion(s): There is an independent association between PCC administration and the composite outcome of death or thromboembolic complications in hospital. PCC may contribute to these events, or be a marker of illness severity, or both. Further exploration is warranted.

Introduction With growing awareness of the importance of rehabilitation, new measures are being developed specifically for use in the intensive care unit (ICU). There are currently 26 measures reported to assess function in ICU survivors. The Physical Function in Intensive care Test scored (PFIT-s) has established clinimetric properties. It is unknown how other functional measures perform in comparison to the PFIT-s or which functional measure may be the most clinically applicable for use within the ICU. The aims of this study were to determine (1) the criterion validity of the Functional Status Score for the ICU (FSS-ICU), ICU Mobility Scale (IMS) and Short Physical Performance Battery (SPPB) against the PFIT-s; (2) the construct validity of these tests against muscle strength; (3) predictive utility of these tests to predict discharge to home; and (4) the clinical applicability. This was a nested study within an ongoing controlled study and an observational study. Methods Sixty-six individuals were assessed at awakening and ICU discharge. Measures included: PFIT-s, FSS-ICU, IMS and SPPB. Bivariate relationships (Spearman’s rank correlation coefficient) and predictive validity (logistic regression) were determined. Responsiveness (effect sizes); floor and ceiling effects; and minimal important differences were calculated. Results Mean ± SD PFIT-s at awakening was 4.7 ± 2.3 out of 10. On awakening a large positive relationship existed between PFIT-s and the other functional measures: FSS-ICU (rho = 0.87, p Conclusions There is high criterion validity for other functional measures against the PFIT-s. The PFIT-s and FSS-ICU are promising functional measures and are recommended to measure function within the ICU. Trial registration Clinicaltrials.gov NCT02214823. Registered 7 August 2014).