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Care of the critically injured burn patient presents unique challenges to the intensivist. Certified burn centers are rare and geographically sparse, necessitating that much of the initial management of patients with severe burn injuries must happen in the pre-burn center setting. Severe burn injuries often lead to a wide range of complications that extend beyond the loss of skin integrity and require specialized care. As such, medical intensivists are often called on to stabilize these critically injured patients. This focused review outlines the clinical care of these medically complex patients, including airway management, postburn complications, volume resuscitation, nutrition, and end-of-life care.

Rationale: Delirium severity and duration are independently associated with higher mortality and morbidity. No studies to date have described a delirium trajectory by integrating both severity and duration. Objectives: The primary aim was to develop delirium trajectories by integrating symptom severity and duration. The secondary aim was to investigate the association among trajectory membership, clinical characteristics, and 30-day mortality. Methods: A secondary analysis of the PMD (Pharmacologic Management of Delirium) randomized control trial (ClinicalTrials.gov Identifier: NCT00842608; N = 531) was conducted. The presence of delirium and symptom severity were measured at least daily for 7 days using the Confusion Assessment Method for the intensive care unit (CAM-ICU) and CAM-ICU-7 (on a scale of 0–7, with 7 being the most severe). Delirium trajectories were defined using an innovative, data-driven statistical method (group-based trajectory modeling [GBTM]) and SAS v9.4. Results: A total of 531 delirious participants (mean age 60 yr [standard deviation = 16], 55% female, and 46% African American) were analyzed. Five distinct delirium trajectories were described (CAM-ICU-7: mean [standard deviation]); mild-brief (CAM-ICU-7: 0.5 [0.5]), severe-rapid recovers (CAM-ICU-7: 2.1 [1.0]), mild-accelerating (CAM-ICU-7: 2.2 [0.9]), severe-slow recovers (CAM-ICU-7: 3.9 [0.9]), and severe-nonrecovers (CAM-ICU-7: 5.9 [1.0]). Baseline cognition and race were associated with trajectory membership. Trajectory membership independently predicted 30-day mortality while controlling for age, sex, race, cognition, illness severity, and comorbidities. Conclusions: This secondary analysis described five distinct delirium trajectories based on delirium symptom severity and duration using group-based trajectory modeling. Trajectory membership predicted 30-day mortality.

Introduction: Severe COVID-19 is associated with high rates of intensive care unit (ICU) delirium and prolonged mechanical ventilation due to acute respiratory distress syndrome. We hypothesize that COVID-19 ICU survivors are at high risk for developing post-intensive care syndrome (PICS), namely long-term cognitive, psychiatric, and physical impairments which persist after ICU hospitalization. Methods: We conducted a prospective observational study at two sites of 49 patients who met the following inclusion criteria: age 18 or older, admitted to the medical ICU, had a positive COVID-19 nasopharyngeal swab, and attended at least one outpatient visit at the Indiana University School of Medicine's Critical Care Recovery Center (CCRC). Patients were administered assessments by trained personnel of cognition (Mini Mental State Exam [MMSE] or Montreal Cognitive Assessment [MoCA]) and self-reported scales for depression (Patient Health Questionarre-9 [PHQ-9]), anxiety (General Anxiety Disorder-7 [GAD-7]), post-traumatic stress disorder (Post Traumatic Symptom Scale-10 [PTSS-10]), quality of life and physical functioning (EuroQol-5D Quality of Life questionnaire [EQ5D QoL], EuroQol-5D5L [EQ5D5L], Healthy Age Brain Care Monitor Self Report [HABC-SR]). Descriptive statistics were computed as frequency, mean, and standard deviation using SPSS. Results: A total of 49 patients were included in the study with 30.6% female, mean age of 51.89 (SD 13.95). Nearly all patients (93.9%) required mechanical ventilation while hospitalized. The average hospital length of stay was 23.06 days (SD 12.3) and the mean days from discharge to initial evaluation in the CCRC was 87.3 (SD 43.2). Scores suggestive of mild cognitive impairment were seen in 23.3% (n = 36) of patients who performed the MMSE and in 37.5% (n = 16) of patients who completed the MoCA. Of the patients who participated in the PHQ-9, 33.3% (n = 36) had an abnormal score consistent with at least mild depression. 21.1% (n = 47) of the patients had abnormal scores on the functional subscale of the HABC-SR. Most notably, the mean quality of life score was 67.8 (SD 19.08) using the EQ5D QoL. Conclusions: ICU hospitalization for severe COVID-19 symptoms may be associated with long-term impairments in cognition, mental health, and physical function consistent with PICS. Larger observational cohort studies are needed to have a deeper understanding of COVID-19-related PICS, risk factors for COVID-19 PICS, and factors affecting recovery from PICS. These results emphasize the importance of continued focused assessment of ICU survivors to help identify and treat impairments in these domains in order to improve quality of life.