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Author(s): Christin Saltnes-Lillegård [sup.1] [sup.2], Tone Rustøen [sup.2] [sup.3], Sigrid Beitland [sup.4], Kathleen Puntillo [sup.5], Milada Hagen [sup.3] [sup.6], Anners Lerdal [sup.7] [sup.8], Kristin Hofsø [sup.1] [sup.3] [sup.9] Author Affiliations: [...], Purpose The purpose of this study is to describe the prevalence, intensity and distress of five symptoms in intensive care unit (ICU) patients and to investigate possible predictive factors associated with symptom intensity. Methods This is a prospective cohort study of ICU patients. A symptom questionnaire (i.e., Patient Symptom Survey) was used to describe the prevalence, intensity and distress of pain, thirst, anxiousness, tiredness, and shortness of breath over seven ICU days. Associations between symptom intensity and possible predictive factors were assessed using the general estimating equation (GEE) model. Results Out of 603 eligible patients, 353 (Sample 2) were included in the present study. On the first ICU day, 195 patients (Sample 1) reported thirst as the most prevalent symptom (66%), with the highest mean intensity score (6.13, 95% confidence interval (CI) [5.7-6.56]). Thirst was the most prevalent (64%) and most intense (mean score 6.05, 95%CI [5.81-6.3]) symptom during seven days in the ICU. Anxiousness was the most distressful (mean score 5.24, 95%CI [4.32-6.15]) symptom on the first day and during seven days (mean score 5.46, 95%CI [4.95-5.98]). During seven days, analgesic administration and sepsis diagnosis were associated with increased thirst intensity. Older age and being mechanically ventilated were associated with decreased pain intensity, and analgesic administration was associated with increased pain intensity. Family visits and female gender were associated with increased intensity of anxiousness and shortness of breath, respectively. Conclusions Self-reporting ICU patients experienced a high and consistent symptom burden across seven days. Certain variables were associated with the degree of symptom intensity, but further research is required to better understand these associations.

BackgroundThe Critical-Care Pain Observation Tool (CPOT) is recommended for evaluating pain behaviors in patients in the intensive care unit who are unable to report pain. The source of the only published Spanish version of the CPOT does not verify that it underwent a formal translation process.ObjectiveTo describe the translation into Spanish and cultural adaptation of the original French version of the CPOT.MethodsKey persons in the translation process included one with a master's degree in translation, a critical care physician, nurse faculty members with vast experience in intensive care units, and the instrument's developer. This team followed the Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcomes Measures as a guide to translate and culturally adapt the CPOT.ResultsThe first Spanish-language version was back translated to French and was also compared with the English version. Revisions necessitated a second version, which was submitted to experts in critical care. Their modifications required a third version, which was back translated to French and discussed with the CPOT developer, after which a fourth version was created. Finally, a linguistic expert proofread the tool, and the translation leaders incorporated the recommendations, thereby obtaining a final Spanish version.ConclusionThe Spanish version is ready to undergo validation with patients in the intensive care unit, which is the next step toward its use in assessing pain behaviors among patients in intensive care units where Spanish is spoken.

Trauma ICU patients may require high and/or prolonged doses of opioids and/or benzodiazepines as part of their treatment. These medications may contribute to drug physical dependence, a response manifested by withdrawal syndrome. We aimed to identify risk factors, symptoms, and clinical variables associated with probable withdrawal syndrome. Design:Prospective exploratory observational study. Setting:Trauma ICU in large medical center in Puerto Rico. Participants:Fifty patients who received opioids and/or benzodiazepines for greater than or equal to 5 days. Measurements and Main Results:Using an opioid/benzodiazepine withdrawal syndrome checklist developed from research in adult ICU patients, the Diagnostic and Statistical Manual of Mental Disorders-5, and the International Classification of Diseases, 10th Edition, we evaluated patients at baseline and for 72 hours after drug weaning was initiated. Patients received opioid/benzodiazepine (88%), opioid (10%), or benzodiazepine (2%). Probable withdrawal syndrome occurred in 44%, questionable withdrawal syndrome in 20%, and no withdrawal syndrome in 18 (36%). Signs that were more frequent in the probable withdrawal syndrome group were agitation, diarrhea, fever, tachypnea, lacrimation, and hyperactive delirium. Patients who developed probable withdrawal syndrome spent almost double the amount of time receiving mechanical ventilation, and length of stay was higher in both ICU and hospital when compared with patients in the other two groups. Age, cumulative opioid dose amounts, and previous drug (opioid/benzodiazepine, cannabis, cocaine, or heroin) use were associated with odds of developing withdrawal syndrome. With the addition of Richmond Agitation-Sedation Scale and delirium to the multilevel analysis, older age no longer had its protective effect, whereas increase in Richmond Agitation-Sedation Scale scores, delirium presence, and increased duration of mechanical ventilation were associated with higher odds of withdrawal syndrome. Conclusions:We identified probable withdrawal syndrome in a sample of trauma ICU patients through observation of several associated symptoms. Significant factors associated with withdrawal syndrome found in this study should be considered when caring for patients being weaned from opioids and/or benzodiazepines. Further validation of the opioid/benzodiazepine withdrawal syndrome checklist is recommended.

Iatrogenic withdrawal syndrome is an increasingly recognized issue among adult patients in the intensive care unit. The prolonged use of opioids and benzodiazepines during the intensive care unit stay and preexisting disorders associated with their use put patients at risk of developing iatrogenic withdrawal syndrome. Although research to date is scant regarding iatrogenic withdrawal syndrome in adult patients in the intensive care unit, it is important to recognize and adequately manage iatrogenic withdrawal syndrome in order to prevent possible negative outcomes during and after a patient's intensive care unit stay. This article discusses in depth 8 studies of iatrogenic withdrawal syndrome among adult patients in the intensive care unit. It also addresses important aspects of opioid and benzodiazepine iatrogenic withdrawal syndrome, including prevalence, risk factors, and assessment and considers its prevention and management.

ObjectiveOur study described the occurrence, assessment, prevention, and management practices of pain, agitation, and delirium (PAD) in four intensive care units (ICUs) from the Puerto Rico Medical Center and compared findings with the 2013 PAD guidelines.MethodsA descriptive study, with repeated bedside measures (two times a day/two times a week) of PAD and review of patient clinical records.ResultsEighty ICU patients (20 per ICU) were evaluated, (median 3 times [IQR, 2-7]). At least once during the assessment period, 57% percent of patients had significant pain and 34% had delirium. Moreover, 46% were deeply sedated, 17.5% had agitation, and 52.5% of patients were within the recommended Richmond Agitation-Sedation Scale (RASS) scores. The Numeric Rating Scale and RASS were the most common tools used by clinicians to evaluate pain and agitation/sedation levels, respectively. Clinicians did not assess pain in patients unable to self-report with any guideline-recommended tools, as was the case for delirium. Fentanyl and morphine were the most commonly used analgesics, while benzodiazepines were used for sedation.ConclusionAlthough pain, agitation, and delirium occurrence were similar to other studies, patients continue to suffer. A gap exists between clinical practices in these ICUs and current guidelines. Strategies that contribute to integrating guidelines into these ICUs should be developed, studied, and implemented.

ObjectiveDecades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle performance and patient-centered outcomes in critical care.DesignProspective, multicenter, cohort study from a national quality improvement collaborative.Setting68 academic, community, and federal ICUs collected data during a 20-month period.Patients15,226 adults with at least one ICU day.InterventionsWe defined ABCDEF bundle performance (our main exposure) in two ways: 1) complete performance (patient received every eligible bundle element on any given day) and 2) proportional performance (percentage of eligible bundle elements performed on any given day). We explored the association between complete and proportional ABCDEF bundle performance and three sets of outcomes: patient-related (mortality, ICU and hospital discharge), symptom-related (mechanical ventilation, coma, delirium, pain, restraint use), and system-related (ICU readmission, discharge destination). All models were adjusted for a minimum of 18 a priori determined potential confounders.Measurements and resultsComplete ABCDEF bundle performance was associated with lower likelihood of seven outcomes: hospital death within 7 days (adjusted hazard ratio, 0.32; CI, 0.17-0.62), next-day mechanical ventilation (adjusted odds ratio [AOR], 0.28; CI, 0.22-0.36), coma (AOR, 0.35; CI, 0.22-0.56), delirium (AOR, 0.60; CI, 0.49-0.72), physical restraint use (AOR, 0.37; CI, 0.30-0.46), ICU readmission (AOR, 0.54; CI, 0.37-0.79), and discharge to a facility other than home (AOR, 0.64; CI, 0.51-0.80). There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001).ConclusionsABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.

OBJECTIVE:To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU. DESIGN:Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017. METHODS:Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified. RESULTS:The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation. CONCLUSIONS:We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

In this review, we seek to highlight how critical illness and critical care affect longer-term outcomes, to underline the contribution of ICU delirium to cognitive dysfunction several months after ICU discharge, to give new insights into ICU acquired weakness, to emphasize the importance of value-based healthcare, and to delineate the elements of family-centered care. This consensus of 29 also provides a perspective and a research agenda about post-ICU recovery.

Objective: To provide clinicians with evidence-based strategies to optimize support of the family of critically ill patients in the ICU.Methods: We used the Council of Medical Specialty Societies principles for the development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis and family-centered care to revise the 2007 Clinical Practice Guidelines for Support of the Family in the Patient-Centered Intensive Care Unit. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome (PICO) question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with guideline development.Results: The scoping review yielded 683 qualitative studies; 228 were used for thematic analysis and PICO question development. The systematic review search yielded 4158 reports after de-duplication and 76 additional studies were added from alerts and hand searches; 238 studies met inclusion criteria. We made 23 recommendations from moderate, low and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice.Conclusions: These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.

Purpose of reviewIs to describe the potential for patients to undergo an acute-to-chronic pain transition after ICU discharge as a result of pain they experienced in ICU and to explore the phenomenon of ICU-acquired opioid dependence. Both topics are timely, in that they can negatively influence patient recovery after critical illness and contribute to post-ICU syndrome.Recent findingsRecognizing and treating pain in patients while they are in the ICU has always been important. However, new knowledge increases the importance of good pain management on patient welfare: recent basic science discoveries on mechanisms of chronic pain development; identification of myriad factors, occurring during the patient's hospital and ICU stay, that put patients at risk for development of chronic pain; the view that a multimodal analgesia treatment approach that is opioid sparing may be the optimum method for acute pain management. Furthermore, recent findings about ICU-acquired opioid dependence provide a foundation for promoting more rigorous assessment, prevention, and treatment of opioid withdrawal in ICU patients.SummaryProviding sufficient analgesia to ICU patients while preventing opioid dependence and withdrawal is essential to promote comfort and rehabilitation. Obtaining this balance requires heightened ICU clinician attention and focused research.

ObjectivesTo describe unique features of neurocritical illness that are relevant to provision of high-quality palliative care; to discuss key prognostic aids and their limitations for neurocritical illnesses; to review challenges and strategies for establishing realistic goals of care for patients in the neuro-ICU; and to describe elements of best practice concerning symptom management, limitation of life support, and organ donation for the neurocritically ill.Data sourcesA search of PubMed and MEDLINE was conducted from inception through January 2015 for all English-language articles using the term "palliative care," "supportive care," "end-of-life care," "withdrawal of life-sustaining therapy," "limitation of life support," "prognosis," or "goals of care" together with "neurocritical care," "neurointensive care," "neurological," "stroke," "subarachnoid hemorrhage," "intracerebral hemorrhage," or "brain injury."Data extraction and synthesisWe reviewed the existing literature on delivery of palliative care in the neurointensive care unit setting, focusing on challenges and strategies for establishing realistic and appropriate goals of care, symptom management, organ donation, and other considerations related to use and limitation of life-sustaining therapies for neurocritically ill patients. Based on review of these articles and the experiences of our interdisciplinary/interprofessional expert advisory board, this report was prepared to guide critical care staff, palliative care specialists, and others who practice in this setting.ConclusionsMost neurocritically ill patients and their families face the sudden onset of devastating cognitive and functional changes that challenge clinicians to provide patient-centered palliative care within a complex and often uncertain prognostic environment. Application of palliative care principles concerning symptom relief, goal setting, and family emotional support will provide clinicians a framework to address decision making at a time of crisis that enhances patient/family autonomy and clinician professionalism.

ContextThirst is a pervasive, intense, and distressing symptom in intensive care unit (ICU) patients. Although thirst may be avoided and/or treated, scant data are available to help providers identify patients most in need.ObjectivesThis study was designed to identify predictors of the presence, intensity, and distress of thirst in ICU patients.MethodsThis descriptive cross-sectional study enrolled 353 patients from three ICUs (medical-surgical, cardiac, and neurological). To measure outcomes, patients were asked to report the presence of thirst (yes/no) and, if present, to rate its intensity and distress on zero to 10 numeric rating scales (10=worst). Predictor variables were demographic (e.g., age), treatment-related (e.g., opioids), and biological (e.g., total body water). Data were analyzed with logistic regression and truncated regression with alpha preset at 0.05.ResultsThirst presence was predicted by high opioid doses (≥ 50 mg), high furosemide doses (>60 mg), selective serotonin reuptake inhibitors, and low ionized calcium. Thirst intensity was predicted by patients not receiving oral fluid and having a gastrointestinal (GI) diagnosis. Thirst distress was predicted by mechanical ventilation, negative fluid balance, antihypertensive medications, and a GI or "other" diagnosis.ConclusionThirst presence was predicted by selected medications (e.g., opioids). Thirst intensity and/or thirst distress were predicted by other treatments (e.g., mechanical ventilation) and medical diagnoses (e.g., GI). This is one of the first studies describing predictors of the multidimensional characteristics of thirst. Clinicians can use these data to target ICU patients whose thirst might warrant treatment.

Rapid response teams (RRTs) can effectively foster discussions about appropriate goals of care and address other emergent palliative care needs of patients and families facing life-threatening illness on hospital wards. In this article, The Improving Palliative Care in the ICU (IPAL-ICU) Project brings together interdisciplinary expertise and existing data to address the following: special challenges for providing palliative care in the rapid response setting, knowledge and skills needed by RRTs for delivery of high-quality palliative care, and strategies for improving the integration of palliative care with rapid response critical care. We discuss key components of communication with patients, families, and primary clinicians to develop a goal-directed treatment approach during a rapid response event. We also highlight the need for RRT expertise to initiate symptom relief. Strategies including specific clinician training and system initiatives are then recommended for RRT care improvement. We conclude by suggesting that as evaluation of their impact on other outcomes continues, performance by RRTs in meeting palliative care needs of patients and families should also be measured and improved.

BackgroundLittle is known about the relationship between body temperature and outcomes in patients with acute respiratory distress syndrome (ARDS). A better understanding of this relationship may provide evidence for fever suppression or warming interventions, which are commonly applied in practice.ObjectiveTo examine the relationship between body temperature and mortality in patients with ARDS.MethodsSecondary analysis of body temperature and mortality using data from the ARDS Network Fluid and Catheter Treatment Trial (n = 969). Body temperature at baseline and on study day 2, primary cause of ARDS, severity of illness, and 90-day mortality were analyzed by using multiple logistic regression.ResultsMean baseline temperature was 37.5°C (SD, 1.1°C; range, 27.2°C-40.7°C). At baseline, fever (≥ 38.3°C) was present in 23% and hypothermia (< 36°C) in 5% of the patients. Body temperature was a significant predictor of 90-day mortality after primary cause of ARDS and score on the Acute Physiology and Chronic Health Evaluation III were adjusted for. Higher temperature was associated with decreased mortality: for every 1°C increase in baseline temperature, the odds of death decreased by 15% (odds ratio, 0.85; 95% CI, 0.73-0.98, P = .03). When patients were divided into 5 temperature groups, mortality was lower with higher temperature (P for trend = .02).ConclusionsEarly in ARDS, fever is associated with improved survival rates. Fever in the acute phase response to lung injury and its relationship to recovery may be an important factor in determining patients' outcome and warrants further study.

BackgroundThe diagnosis of breast cancer, in combination with the anticipation of surgery, evokes fear, uncertainty, and anxiety in most women.ObjectiveStudy purposes were to examine in patients who underwent breast cancer surgery how ratings of state anxiety changed from the time of the preoperative assessment to 6 months after surgery and to investigate whether specific demographic, clinical, symptom, and psychosocial adjustment characteristics predicted the preoperative levels of state anxiety and/or characteristics of the trajectories of state anxiety.Interventions/methodsPatients (n = 396) were enrolled preoperatively and completed the Spielberger State Anxiety inventory monthly for 6 months. Using hierarchical linear modeling, demographic, clinical, symptom, and psychosocial adjustment characteristics were evaluated as predictors of initial levels and trajectories of state anxiety.ResultsPatients experienced moderate levels of anxiety before surgery. Higher levels of depressive symptoms and uncertainty about the future, as well as lower levels of life satisfaction, less sense of control, and greater difficulty coping, predicted higher preoperative levels of state anxiety. Higher preoperative state anxiety, poorer physical health, decreased sense of control, and more feelings of isolation predicted higher state anxiety scores over time.ConclusionsModerate levels of anxiety persist in women for 6 months after breast cancer surgery.Implications for practiceClinicians need to implement systematic assessments of anxiety to identify high-risk women who warrant more targeted interventions. In addition, ongoing follow-up is needed to prevent adverse postoperative outcomes and to support women to return to their preoperative levels of function.

ObjectiveThis review highlights benefits that patients, families and clinicians can expect to realize when palliative care is intentionally incorporated into the PICU.Data sourcesWe searched the MEDLINE database from inception to January 2014 for English-language articles using the terms "palliative care" or "end of life care" or "supportive care" and "pediatric intensive care." We also hand-searched reference lists and author files and relevant tools on the Center to Advance Palliative Care website.Study selectionTwo authors (physicians with experience in pediatric intensive care and palliative care) made final selections.Data extractionWe critically reviewed the existing data and tools to identify strategies for incorporating palliative care into the PICU.Data synthesisThe Improving Palliative Care in the ICU Advisory Board used data and experience to address key questions relating to: pain and symptom management, enhancing quality of life, communication and decision-making, length of stay, sites of care, and grief and bereavement.ConclusionsPalliative care should begin at the time of a potentially life-limiting diagnosis and continue throughout the disease trajectory, regardless of the expected outcome. Although the PICU is often used for short term postoperative stabilization, PICU clinicians also care for many chronically ill children with complex underlying conditions and others receiving intensive care for prolonged periods. Integrating palliative care delivery into the PICU is rapidly becoming the standard for high quality care of critically ill children. Interdisciplinary ICU staff can take advantage of the growing resources for continuing education in pediatric palliative care principles and interventions.

Thirst, as a symptom, has long been considered the most prevalent clinical complaint patients voice in healthcare settings. Yet, rarely have researchers examined thirst by its correlation with physiologic factors. This review was undertaken to examine the relationships between thirst ratings and factors mediating its primary physiologic correlates: plasma osmolality (pOsm) and arginine vasopressin peptide (AVP). A literature search was undertaken to identify clinical studies in human subjects that investigated the relationship of thirst to specific physiologic thirst-related correlates and associated thirst mediators. Thirst was induced in 17 selected clinical studies by hyperosmolar infusion, through water deprivation or exercise weight-loss regimens. Positive linear relationships between the subjects' thirst ratings and rising serum pOsm levels confirmed the presence of intact osmotic thirst drives. However, there were significant variations in normal compensatory rises in AVP levels that followed the rises in plasma osmolality after the subjects were exposed to cold, physical pre-conditioning and water immersion tests. Notably, older adults in the studies reported diminished thirst ratings. Weak correlations suggest that angiotensin II may play only a minor role in thirst mediation. Atrial natriuretic hormone's inhibitory effect on thirst was inconsistent. Findings indicated that older adults are at higher risk for profound dehydration due to sensory deficits along with failure to correct volume losses. The thirst trials results support the close correlation between serum pOsm values and patients' thirst ratings, with the exception of the older adult.

PurposeTo test an intervention bundle for thirst intensity, thirst distress, and dry mouth, which are among the most pervasive, intense, distressful, unrecognized, and undertreated symptoms in ICU patients, but for which data-based interventions are lacking.MethodsThis was a single-blinded randomized clinical trial in three ICUs in a tertiary medical center in urban California. A total of 252 cognitively intact patients reporting thirst intensity (TI) and/or thirst distress (TD) scores ≥3 on 0-10 numeric rating scales (NRS) were randomized to intervention or usual care groups. A research team nurse (RTN#1) obtained patients' pre-procedure TI and TD scores and reports of dry mouth. She then administered a thirst bundle to the intervention group: oral swab wipes, sterile ice-cold water sprays, and a lip moisturizer, or observed patients in the usual care group. RTN#2, blinded to group assignment, obtained post-procedure TI and TD scores. Up to six sessions per patient were conducted across 2 days.ResultsMultilevel linear regression determined that the average decreases in TI and TD scores from pre-procedure to post-procedure were significantly greater in the intervention group (2.3 and 1.8 NRS points, respectively) versus the usual care group (0.6 and 0.4 points, respectively) (p < 0.05). The usual care group was 1.9 times more likely than the intervention group to report dry mouth for each additional session on day 1.ConclusionThis simple, inexpensive thirst bundle significantly decreased ICU patients' thirst and dry mouth and can be considered a practice intervention for patients experiencing thirst.

Depressive symptoms are common in women with breast cancer. This study evaluated how ratings of depressive symptoms changed from the time of the preoperative assessment to 6 months after surgery and investigated whether specific demographic, clinical, and symptom characteristics predicted preoperative levels of and/or characteristics of the trajectories of depressive symptoms. Characteristics that predicted higher preoperative levels of depressive symptoms included being married/partnered; receipt of adjuvant chemotherapy; more fear of metastasis; higher levels of trait anxiety, state anxiety, sleep disturbance, problems with changes in appetite; more hours per day in pain; and lower levels of attentional function. Future studies need to evaluate associations between anxiety, fears of recurrence, and uncertainty, as well as personality characteristics and depressive symptoms.

PurposePain, dyspnea, and thirst are three of the most prevalent, intense, and distressing symptoms of intensive care unit (ICU) patients. In this report, the interdisciplinary Advisory Board of the Improving Palliative Care in the ICU (IPAL-ICU) Project brings together expertise in both critical care and palliative care along with current information to address challenges in assessment and management.MethodsWe conducted a comprehensive review of literature focusing on intensive care and palliative care research related to palliation of pain, dyspnea, and thirst.ResultsEvidence-based methods to assess pain are the enlarged 0-10 Numeric Rating Scale (NRS) for ICU patients able to self-report and the Critical Care Pain Observation Tool or Behavior Pain Scale for patients who cannot report symptoms verbally or non-verbally. The Respiratory Distress Observation Scale is the only known behavioral scale for assessment of dyspnea, and thirst is evaluated by patient self-report using an 0-10 NRS. Opioids remain the mainstay for pain management, and all available intravenous opioids, when titrated to similar pain intensity end points, are equally effective. Dyspnea is treated (with or without invasive or noninvasive mechanical ventilation) by optimizing the underlying etiological condition, patient positioning and, sometimes, supplemental oxygen. Several oral interventions are recommended to alleviate thirst. Systematized improvement efforts addressing symptom management and assessment can be implemented in ICUs.ConclusionsRelief of symptom distress is a key component of critical care for all ICU patients, regardless of condition or prognosis. Evidence-based approaches for assessment and treatment together with well-designed work systems can help ensure comfort and related favorable outcomes for the critically ill.

Open visitation has been highly recommended by critical care groups but is not prevalent in practice. Here we discuss the present study on current visitation practices in US ICUs and discuss several factors affecting open visitation. We conclude with suggestions on achieving more liberal visitation practices.

Open visitation has been highly recommended by critical care groups but is not prevalent in practice. Here we discuss the present study on current visitation practices in US ICUs and discuss several factors affecting open visitation. We conclude with sugge

Critically ill patients often report distressful episodes of severe thirst, but the complex biochemical, neurohormonal mechanisms that regulate this primal sensation still elude clinicians. The most potent stimuli for thirst are subtle increases in plasma osmolality. These minute changes in osmolality stimulate central osmoreceptors to release vasopressin (also known as antidiuretic hormone). Vasopressin in turn acts on the kidneys to promote the reabsorption of water to correct the increased osmolality. If this compensatory mechanism fails to decrease osmolality, then thirst is triggered to motivate drinking. In contrast, thirst induced by marked volume loss, or hypovolemic thirst, is subject to the tight osmoregulation of the renin-angiotensin aldosterone system and accompanying adrenergic agonists. Understanding the essential role that thirst plays in salt and water regulation can provide clinicians with a better appreciation for the complex physiology that underlies this intense sensation.

Purpose of the researchLittle is known about the relationships between pain, anxiety, and depression in women prior to breast cancer surgery. The purpose of this study was to evaluate for differences in anxiety, depression, and quality of life (QOL) in women who did and did not report the occurrence of breast pain prior to breast cancer surgery. We hypothesized that women with pain would report higher levels of anxiety and depression as well as poorer QOL than women without pain.Methods and sampleA total of 390 women completed self-report measures of pain, anxiety depression, and QOL prior to surgery.Key resultsWomen with preoperative breast pain (28%) were significantly younger, had a lower functional status score, were more likely to be Non-white and to have gone through menopause. Over 37% of the sample reported clinically meaningful levels of depressive symptoms. Almost 70% of the sample reported clinically meaningful levels of anxiety. Patients with preoperative breast pain reported significantly higher depression scores and significantly lower physical well-being scores. No between group differences were found for patients' ratings of state and trait anxiety or total QOL scores.ConclusionsOur a priori hypotheses were only partially supported. Findings from this study suggest that, regardless of pain status, anxiety and depression are common problems in women prior to breast cancer surgery.

ObjectiveDetermine levels of agreement among intensive care unit patients and their family members, nurses, and physicians (proxies) regarding patients' symptoms and compare levels of mean intensity (i.e., the magnitude of a symptom sensation) and distress (i.e., the degree of emotionality that a symptom engenders) of symptoms among patients and proxy reporters.DesignProspective study of proxy reporters of symptoms in seriously ill patients.SettingsTwo intensive care units in a tertiary medical center in the Western United States.PatientsTwo hundred and forty-five intensive care unit patients, 243 family members, 103 nurses, and 92 physicians.InterventionsNone.Measurements and main resultsOn the basis of the magnitude of intraclass correlation coefficients, where coefficients from .35 to .78 are considered to be appropriately robust, correlation coefficients between patients' and family members' ratings met this criterion (≥.35) for intensity in six of ten symptoms. No intensity ratings between patients and nurses had intraclass correlation coefficients >.32. Three symptoms had intensity correlation coefficients of ≥.36 between patients' and physicians' ratings. Correlation coefficients between patients and family members were >.40 for five symptom-distress ratings. No symptoms had distress correlation coefficients of ≥.28 between patients' and nurses' ratings. Two symptoms had symptom-distress correlation coefficients between patients' and physicians' ratings at >.39. Family members, nurses, and physicians reported higher symptom-intensity scores than patients did for 80%, 60%, and 60% of the symptoms, respectively. Family members, nurses, and physicians reported higher symptom-distress scores than patients did for 90%, 70%, and 80% of the symptoms, respectively.ConclusionsPatient-family intraclass correlation coefficients were sufficiently close for us to consider using family members to help assess intensive care unit patients' symptoms. Relatively low intraclass correlation coefficients between intensive care unit clinicians' and patients' symptom ratings indicate that some proxy raters overestimate whereas others underestimate patients' symptoms. Proxy overestimation of patients' symptom scores warrants further study because this may influence decisions about treating patients' symptoms.

Pain remains a significant problem for patients hospitalized in intensive care units (ICUs). As research has shown, for some of these patients pain might even persist after discharge and become chronic. Exposure to intense pain and stress during medical and nursing procedures could be a risk factor that contributes to the transition from acute to chronic pain, which is a major disruption of the pain neurological system. New evidence suggests that physiological alterations contributing to chronic pain states take place both in the peripheral and central nervous systems. The purpose of this paper is to: 1) review cutting-edge theories regarding pain and mechanisms that underlie the transition from acute to chronic pain, such as increases in membrane excitability of peripheral and central nerve fibers, synaptic plasticity, and loss of the function of descending inhibitory pain fibers; 2) provide information on the association between the immune system and pain and its crucial contribution to development of chronic pain syndromes, and 3) discuss mechanisms at brain levels in the nervous system and their contribution to affective (i.e., emotional) states associated with chronic pain conditions. Finally, we will offer suggestions for ICU clinical interventions to attempt to prevent the transition from acute to chronic pain.

Blunt thoracic injury (BTI) in older adults can lead to grave illness, permanent disability, and even death. Using Haddon's phase-factor matrix model, this article examines the phenomenon of BTI in older adults. Preventive, diagnostic, and treatment interventions are discussed from the perspective of the pre-event, event, and post-event phases. Relevant physiological and pathophysiological changes regarding senescence and injury are reviewed, as are the common mechanisms of blunt trauma and anatomic injury patterns seen in older adults. Considerations for clinical interventions and future research are also presented.

Author(s): Kathleen A. Puntillo [sup.1], Adeline Max [sup.2], Jean-Francois Timsit [sup.3], Stephane Ruckly [sup.4], Gerald Chanques [sup.5] [sup.6], Gemma Robleda [sup.7], Ferran Roche-Campo [sup.8], Jordi Mancebo [sup.7], Jigeeshu V. Divatia [...], Purpose The intensity of procedural pain in intensive care unit (ICU) patients is well documented. However, little is known about procedural pain distress, the psychological response to pain. Methods Post hoc analysis of a multicenter, multinational study of procedural pain. Pain distress was measured before and during procedures (0-10 numeric rating scale). Factors that influenced procedural pain distress were identified by multivariable analyses using a hierarchical model with ICU and country as random effects. Results A total of 4812 procedures were recorded (3851 patients, 192 ICUs, 28 countries). Pain distress scores were highest for endotracheal suctioning (ETS) and tracheal suctioning, chest tube removal (CTR), and wound drain removal (median [IQRs] = 4 [1.6, 1.7]). Significant relative risks (RR) for a higher degree of pain distress included certain procedures: turning (RR = 1.18), ETS (RR = 1.45), tracheal suctioning (RR = 1.38), CTR (RR = 1.39), wound drain removal (RR = 1.56), and arterial line insertion (RR = 1.41); certain pain behaviors (RR = 1.19-1.28); pre-procedural pain intensity (RR = 1.15); and use of opioids (RR = 1.15-1.22). Patient-related variables that significantly increased the odds of patients having higher procedural pain distress than pain intensity were pre-procedural pain intensity (odds ratio [OR] = 1.05); pre-hospital anxiety (OR = 1.76); receiving pethidine/meperidine (OR = 4.11); or receiving haloperidol (OR = 1.77) prior to the procedure. Conclusions Procedural pain has both sensory and emotional dimensions. We found that, although procedural pain intensity (the sensory dimension) and distress (the emotional dimension) may closely covary, there are certain factors than can preferentially influence each of the dimensions. Clinicians are encouraged to appreciate the multidimensionality of pain when they perform procedures and use this knowledge to minimize the patient's pain experience.