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It is estimated that 50 million people in the United States provide care for a chronically ill, disabled, or aged family member or friend.1 For caregivers of persons with cancer and dementia, extensive evidence shows that negative psychological and behavioral consequences are common and may be linked to a decline in caregivers’ overall health.2,3 Caregivers of critically ill patients also experience high levels of stress. Recovery from critical illness may occur quickly or gradually over an extended period. The term chronically critically ill (CCI) is commonly used to describe persons who require an extended duration of mechanical ventilation and hospitalization after recovery from critical illness.4 Evidence from a variety of sources suggests that growing numbers of caregivers will face the need to support CCI patients after hospital discharge. Demand for critical care, including mechanical ventilation, is anticipated to increase sharply as the generation of “baby boomers” grows to 20% of the total US population by 2030.5 Currently, 5% to 20% of patients in intensive care units (ICUs) require mechanical ventilation for periods that can extend to weeks or months,6 and those percentages are expected to increase.7,8 It has been estimated that by 2020 more than 600 000 patients per year will require extended critical care support.9 Such patients encounter enormous difficulties, including psychoemotional stress, reduced physical and neurocognitive function, symptom burden, and frequent hospital readmissions.7,10,11 Concurrently, family caregivers must cope with financial, emotional, and physical stressors.12 In several prior studies,12–18 caregivers of CCI patients were surveyed about their psychological responses. Despite heterogeneous characteristics of patients (eg, severity of illness, days of mechanical ventilation) and follow-up intervals (2 to 23 months), findings uniformly included a high incidence of depression12–18 that was comparable to the incidence of depression in caregivers of the frail elderly and twice the incidence of depression in the general population. Douglas and Daly12 reported decreased physical health and increased risk of depression in caregivers of CCI patients that exceeded reports for other populations of patients who require long-term caregiving, such as patients with Alzheimer’s disease and patients with spinal cord injury. When patients remained institutionalized, family caregivers reported a higher incidence of depression and burden, more disruption in daily schedules, more health problems, and less family support.14,16 Depressive symptoms decreased over time,13,18 but remained higher than in the general population. Notably, in an analysis of a national data set comprising almost 300 000 cases, a significantly higher risk of death was reported in spouses of persons who received mechanical ventilation for 4 days or longer.19 Reports of prior studies13,16–18 have described the challenges encountered by caregivers of CCI patients. However, most did not identify the specific lifestyle restrictions, distress, or problem behaviors of patients that were of most concern. In an effort to identify ways to support caregivers of CCI patients, it may be helpful to explore longitudinal changes in caregiver response as influenced by changes in the characteristics of patients. It is also important to identify specific areas that cause caregivers to experience greater lifestyle restriction and distress. Therefore, the purpose of this study was to describe perceived lifestyle restrictions and distress among caregivers of CCI patients at 1 and 6 months after ICU discharge. We also explored how caregivers’ lifestyle restrictions and distress differed according to the characteristics of the patients and the caregivers.

• Background Many academic medical centers employ nurse practitioners as substitutes to provide care normally supplied by house staff.• Objective To compare outcomes in a subacute medical intensive care unit of patients managed by a team consisting of either an acute care nurse practitioner and an attending physician or an attending physician and critical care/pulmonary fellows.• Methods During a 31-month period, in 7-month blocks of time, 526 consecutive patients admitted to the unit for more than 24 hours were managed by one or the other of the teams. Patients managed by the 2 teams were compared for a variety of outcomes.• Results Patients managed by the 2 teams did not differ significantly for any workload, demographic, or medical condition variable. The patients also did not differ in readmission to the high acuity unit (P = .25) or subacute unit (P = .44) within 72 hours of discharge or in mortality with (P = .25) or without (P = .89) treatment limitations. Among patients who had multiple weaning trials, patients managed by the 2 teams did not differ in length of stay in the subacute unit (P = .42), duration of mechanical ventilation (P = .18), weaning status at time of discharge from the unit (P = .80), or disposition (P = .28). Acute Physiology Scores were significantly different over time (P = .046). Patients managed by the fellows had more reintubations (P=.02).• Conclusions In a subacute intensive care unit, management by the 2 teams produced equivalent outcomes.

• Background Studies suggest that patients who undergo off-pump coronary artery bypass grafting (OPCABG) have fewer short-term complications and use fewer inpatient resources than do patients who undergo standard coronary artery bypass grafting (CABG) with extracorporeal circulation. However, dissimilarity between groups in risk factors for complications has hindered interpretation of results.• Objectives To compare the prevalence of selected complications (atrial fibrillation, stroke, reoperation, and bleeding) and inpatient resource utilization (length of stay, discharge disposition, total charges) between subjects undergoing primary isolated CABG or OPCABG who were matched with respect to key risk factors.• Methods Retrospective, causal-comparative survey conducted in 1 center for 18 months. Patients who underwent primary isolated CABG or OPCABG were matched for sex, age (within 2 years), left ventricular ejection fraction (within 0.05), and graft-patient ratio (exact match) and compared for prevalence of new-onset atrial fibrillation, stroke, reoperation within 24 hours, and bleeding. Statistical analysis included Wilcoxon and t tests for paired comparisons.• Results The sample (107 matched pairs) was 63% male, with a mean age of 66 (SD 9.5) years, a mean left ventricular ejection fraction of 0.51 (SD 0.13), and a mean graft-patient ratio of 3.41 (SD 0.74). The 2 groups did not differ significantly in New York Heart Association class (P = .43), Acute Physiology and Chronic Health Evaluation III score (P = .22), postoperative β-blocker use (P = .73), or comorbid conditions. None of the complications examined differed significantly between pairs.• Conclusion Patients with comparable risk profiles have similar prevalences of selected complications after CABG and OPCABG.

• Background Most lung transplant recipients experience improvement in their underlying pulmonary condition but are faced with the threat of allograft rejection, the primary determinant of long-term survival. Several studies examined predictors of rejection, but few focused on the early period after transplantation.• Objectives To describe the pattern and predictors of early rejection during the first year after transplantation to guide the development of interventions to facilitate earlier detection and treatment of rejection.• Methods Data for donor, recipient, and posttransplant variables were retrieved retrospectively for 250 recipients of single or double lung transplants.• Results Most recipients (85%) had at least 1 episode of acute rejection; 33% had a single episode; 23% had recurrent rejection; 3% had persistent rejection; 13% had refractory rejection; and 14% had clinicopathological evidence of chronic rejection. Serious rejection (refractory acute rejection or chronic rejection) developed in 27% of recipients. Compared with other recipients, recipients who had serious rejection had more episodes of acute rejection (P = .004), and the first acute episodes occurred sooner after transplantation (P = .01) and were of a higher grade (P = .002).• Conclusions Recipients who experienced higher grades for their first episode of acute rejection (P=.03) and higher cumulative rejection scores (P = .004) were significantly more likely than other recipients to have serious rejection during the first year after transplantation.

• Background Little is known about aspects of practice that differ between acute care nurse practitioners and physicians that might affect patients’ outcomes.• Objective To determine if time spent in work activities differs between an acute care nurse practitioner and physicians in training (pulmonary/critical care fellows) managing patients’ care in a step-down medical intensive care unit.• Methods Work sampling techniques were used to collect data when the nurse practitioner had 6 months’ or less experience in the role (T1), after the nurse practitioner had 12 months’ experience in the role (T2), and when physicians in training provided care on a rotational schedule (nurse practitioner not present, T3). These data were used to estimate the time spent in direct management of patients, coordination of care, and nonunit activities.• Results Results for T1 and T2 were similar. When T2 and T3 were compared, the nurse practitioner and the physicians in training spent approximately half their time in activities directly related to management of patients (40% vs 44%, not significantly different). The nurse practitioner spent more time in activities related to coordination of care (45% vs 18%; P < .001) and less time in nonunit activities (15% vs 37%; P < .001).• Conclusion The nurse practitioner and the physicians in training spent a similar proportion of time performing required tasks. Because of training requirements, physicians spent more time than the nurse practitioner in nonunit activities. Conversely, the nurse practitioner spent more time interacting with patients and patients’ families and collaborating with health team members.

• Background Tracheal gas insufflation reduces inspired tidal volume and minute ventilation in spontaneously breathing patients and may facilitate weaning from mechanical ventilation.• Objective To determine if tracheal gas insufflation can reduce ventilatory demand during weaning trials in patients who require prolonged mechanical ventilation.• Methods A reduction in ventilatory demand was defined as a relative decrease in tidal volume, minute ventilation, and mean inspiratory flow during trials with tracheal gas insufflation compared with the values during trials without this therapy. A total of 14 subjects underwent T-piece trials with and without insufflation (flow rate 6 L/min) on 2 consecutive days; the order of insufflation was randomized. Tidal volume, minute ventilation, and mean inspiratory flow were measured at baseline (without insufflation) and 2 hours later.• Results Differences in ventilatory demand were not significant when comparisons were made for condition (tracheal gas insufflation vs no flow) or time (baseline vs 2 hours) for the total group (P = .48). Subjects were classified post hoc as responders (n = 9) or nonresponders (n = 5). Comparisons between responders and nonresponders indicated a significant (P = .02) 3-way multivariate interaction for group (responder vs nonresponder), condition (tracheal gas insufflation vs no flow), and time (baseline vs 2 hours) for ventilatory demand variables.• Conclusion Tracheal gas insufflation can reduce ventilatory demand during weaning trials in some patients who require mechanical ventilation.

• Background Many benefits and adverse effects of positioning are related to changes in ventilation and perfusion. A number of unique factors related to the allograft make the effects of positioning difficult to determine in single-lung transplant recipients.• Objectives To determine the effect of 3 body positions (supine, lateral with allograft lung down, and lateral with native lung down) on oxygenation and blood flow in single-lung transplant recipients in the 24 hours immediately after surgery.• Methods A quasi-experimental repeated-measures design with stratified assignment to 1 of 3 different sequencing patterns for turning group was used to study 15 transplant recipients, 9 with emphysema and 6 with fibrosis. Oxygenation, ventilation, and blood flow measures (heart rate, blood pressure) were assessed after each turn. The effect of ischemic reperfusion injury was also explored.• Results The oxygenation, ventilation, and blood flow variables did not differ significantly across group, diagnosis, or time. Oxygenation variables measured when the allograft lung was dependent did not differ significantly from such measurements obtained when the native lung was dependent.• Conclusions No single position maximizes oxygenation in the immediate postoperative period in single-lung transplant recipients. Although a single standard protocol for positioning cannot be supported, the study does support the idea that transplant recipients can be safely turned in the immediate postoperative period without compromising oxygenation or hemodynamic status.