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Improving Outcomes for Critically Ill Patients

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Dale Needham and colleagues investigate a novel combination of exercise and protein supplementation for patients early during ICU treatment.

For over 15 years, Dale Needham has devoted himself to understanding and improving the outcomes of critically ill patients. As director of the Outcomes After Critical Illness and Surgery (OACIS) group, a multidisciplinary clinical and research group at Johns Hopkins, he and his colleagues have become well known for designing and implementing major changes in patient care in the intensive care unit — including altering approaches to sedation, delirium and physical rehabilitation — so that patients remain awake and receive intensive rehabilitation in the ICU.

They also are recognized for innovative research projects, many funded by the National Institutes of Health, to study longer-term outcomes, after ICU discharge, such as cognitive and physical impairments.

“In a traditional critical care world, success equals the patient leaving the ICU alive,” says Needham, a professor of pulmonary and critical care medicine and of physical medicine and rehabilitation at the Johns Hopkins University School of Medicine. “But in fact, as you study the physical, cognitive and mental health problems of these survivors, you recognize that success should be defined quite differently.”

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“As you study the physical, cognitive and mental health problems of these survivors, you recognize that success should be defined quite differently.” —Dale Needham

In a first-of-its-kind study, Needham’s team is investigating a novel combination of protein supplementation and exercise early in the ICU stay, while patients are still very sick on life support.

The rational for this study is that ICU survivors experience rapid loss of lean muscle mass with resulting weakness in the ICU, says Needham. That weakness is associated with patients being unable to return to work, having worse quality of life and being more likely to die. Just as weightlifters consume extra protein to build muscle, investigators want to evaluate if that practice has similar benefits for critically ill patients, improving short-term physical functioning, body composition, and patient-reported outcomes six months following discharge. On a daily basis, participants will receive amino acids by IV and exercise via in-bed cycle ergometry — a motorized device that takes patients’ legs through a bicycling motion even while lying in bed, with patients actively participating as much as feasible.

The group is currently analyzing results of another recently-completed cycle ergometry study that included electrical stimulation of the leg muscles to cause them to contract and help pedal the bike.

In other avenues of research, Needham is working with faculty colleagues Martin Brodsky in the Department of Physical Medicine and Rehabilitation, and Vinciya Pandian in the School of Nursing, to better understand laryngeal injury and changes in voice after ICU patients’ breathing tubes are removed. He also is participating in a Department of Defense-funded project with investigators at Intermountain Medical Center (Utah), to study ICU survivors’ medical needs after discharge to home. “Patients who have been critically ill leave the hospital with lots of medical needs and follow-up that is supposed to occur,” says Needham. They will systematically document medical-related needs of survivors, like attending follow-up appointments, versus the activities that are actually completed to understand if any gaps in care are associated with outcomes such as hospital readmission.

“We’re also pushing the field further via novel observational studies to investigate other challenges for ICU survivors,” Needham says, noting the ease in which he can do multidisciplinary research with occupational therapists, physical therapists, rehabilitation psychologists and other professionals in a large academic center. These studies check in with patients months to years after their ICU stay to assess outcomes.

The work has lent itself to an annual continuing education conference on critical care rehabilitation that attracts some 700 health professionals from around the world. Needham also organizes an annual Asia-Pacific ICU rehabilitation conference and a free meeting immediately prior to the annual American Thoracic Society international scientific conference.

To learn more about the OACIS group, see www.hopkinsmedicine.org/OACIS.


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