Spotlight

Post-traumatic stress in the intensive care unit

Enhanced recovery after surgery (ERAS) for head and neck oncology patients was first introduced in 2017 and was found to improve patient outcomes, in line with results from other surgical specialties. This article presents a rapid recovery protocol (RRP) to further enhance perioperative care in conjunction with the ERAS protocol, for patients undergoing ablative surgery together with free flap reconstruction and tracheostomy. A prospective multidisciplinary approach was adopted to identify a specific cohort of patients who would benefit from the RRP. Of 26 patients who fulfilled the eligibility criteria, 16 completed the RRP. On average, these patients spent 5 days less with a tracheostomy and were discharged 7 days sooner when compared to a matched control group of nine patients on the standard postoperative care pathway. This resulted in an approximate monetary saving of £ 9955 per patient for the hospital trust. These results demonstrate that the feasibility study should be rolled out further, as the RRP not only decreased the length of stay but also provided substantial monetary savings without compromising patient outcomes.

Little is known about patient-reported outcomes (PROs) following abdominal trauma. We hypothesized that patients undergoing definitive laparotomy (DEF) would have better PROs compared to those treated with damage control laparotomy (DCL).

The DCL Trial randomized DEF versus DCL in abdominal trauma. PROs were measured using the European Quality of Life-5 Dimensions-5 Levels (EQ-5D) questionnaire at discharge and six months postdischarge (1 = perfect health, 0 = death, and <0 = worse than death) and Posttraumatic Stress Disorder (PTSD) Checklist-Civilian. Unadjusted Bayesian analysis with a neutral prior was used to assess the posterior probability of achieving minimal clinically important difference.

Of 39 randomized patients (21 DEF versus 18 DCL), 8 patients died (7 DEF versus 1 DCL). Of those who survived, 28 completed the EQ-5D at discharge (12 DEF versus 16 DCL) and 25 at 6 mo (12 DEF versus 13 DCL). Most patients were male (79%) with a median age of 30 (interquartile range (IQR) 21-42), suffered blunt injury (56%), and were severely injured (median injury severity score 33, IQR 21 – 42). Median EQ-5D value at discharge was 0.20 (IQR 0.06 – 0.52) DEF versus 0.31 (IQR -0.03 – 0.43) DCL, and at six months 0.51 (IQR 0.30 – 0.74) DEF versus 0.50 (IQR 0.28 – 0.84) DCL. The posterior probability of minimal clinically important difference DEF versus DCL at discharge and six months was 16% and 23%, respectively.

Functional deficits for trauma patients persist beyond the acute setting regardless of laparotomy status. These deficits warrant longitudinal studies to better inform patients on recovery expectations.

Developed countries report higher ICU-related mental-health complications. The absence of non-ICU comparators limits interpretation and comparability across socioculturally diverse populations. Having found low levels of mental health complications in our ICU patients, we compared anxiety, depression, posttraumatic stress symptoms (PTSS), quality of life (QOL), and self-reported stressors in ICU (n ​= ​28), ward (n ​= ​34) patients and family caregivers (n ​= ​30) in a cross-sectional study in a tertiary teaching hospital. Hospital Anxiety and Depression Scale (HADS), Impact of Events revised IES-R, European Quality of Life 5 Dimensions 3 levels (EQ5D 3L) were used. Clinically relevant anxiety, depression (HADS ≥8), and PTSS (IES-R ≥30) were comparable amongst the ICU patients (46.4%, 46.4%, 10.7%), ward patients (53.3%, 30.0%, 6.7%), and caregivers (55.9%, 29.4%, 0%) respectively. Avoidance as PTSS subgroup was significantly higher in ICU patients and caregivers. IES-R scores were significantly less when only the ICU experiences were considered. QOL was significantly worse in ICU patients. Self-reported stressors were comparable in the groups; however after correcting baseline factors, unemployment contributed significantly to higher PTSS, anxiety and depression. While the rates of anxiety/depression were similar, lower PTSS in comparison to reports from developed countries suggest future studies to focus ICU experience, confounding non-clinical stressors and cultural issues.

Liver transplantation (LT) is stressful experience which can cause psychological trauma but also positive growth. We examined the prevalence of transplant related post-traumatic stress disorder symptoms (PTSD) and post-traumatic growth (PTG) in a cohort of alcohol-associated liver disease (ALD) LT recipients. We also examined whether PTG or PTSD symptoms were associated with post-LT alcohol use.

Cross sectional survey of 51 ALD LT recipients one-year post-LT assessed PTSD symptoms, PTG, stress, self-efficacy, social support, and alcohol use.

18% endorsed symptoms of PTSD; 59% endorsed high PTG. PTSD symptoms and PTG were not associated. 18% drank alcohol; 10% returned to health harmful use. Neither PTSD symptoms nor PTG were associated with alcohol use. Less self-efficacy to abstain and thoughts of drinking were associated with alcohol use.

A substantial percentage of ALD LT patients had transplant-related PTSD symptoms and high PTG. Alcohol use was not associated with PTSD symptoms or PTG. Lower self-efficacy to abstain from alcohol use may provide a valuable clinical measure to assess risk for post-LT use. Clinical screening for PTSD would be beneficial as effective treatments for PTSD exist. Whether PTG can be facilitated in transplant recipients would be a valuable future line of inquiry.