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5583.ppt

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  • 1. Health related quality of life (QoL) in patients recovering from long-term ICU-stay after difficult weaning (prolonged MV) Prof. Dr. Bernd Schönhofer Dpt of respiratory and critical care medicine Krankenhaus Oststadt-Heidehaus Klinikum Region Hannover Germany
  • 2. Contents Background ICU-associated issues influencing QoL QoL after discharge Strategies to improve QoL after prolonged MV Some open questions
  • 3. Technology and improved levels of care have increased patients “survivors of catastrophic illness”. These patients commonly require prolonged and difficult weaning. McIntyre NR, et al. CHEST 2005; 128:3937–3 Management of Patients Requiring PMV Consensus Conference
  • 4. • Exceeding a specific number of days of MV (range 2-29 days) • Receiving a tracheostomy for PMV • Exceeding a specific number of days in ICU (range 4-14 days) • Different definitions for prolonged ICU stay in community (10 d) or teaching hospitals (21 d) McIntyre NR, et al. CHEST 2005; 128:3937–39 “PMV” - Arbitrary definitions
  • 5. • ARDS Rubenfeld NEJM 2005 • Crit illness PNP or ICU-AP De Jonghe JAMA 2002 • Trachestomy Frutos-Vivar CCM 2005 • Age Wesley Ann Inter Med 2002 • Comorbidities Chelluri CCM 2004 • Premorbid functional status Carson CCM 1999 Risk factors for PMV
  • 6. 2002 225.2 /100.000 Patients Cox CE, et al. Critical Care Medicine 2004; 32: 2219-2226 1993 143.9 /100.000 Patients Increase in PMV in North Carolina, 1993-2002 Increasing incidence of difficult weaning
  • 7. Spicher and White Arch Intern Med 1987 Gracey Chest 1992 Douglas CCM 2002 Combes CCM 2003 Engoren Chest 2003 Cumulative 1-year survival 30 %Hospital survival about 50% Curr Opin Crit Care 2006; 12: 405-411
  • 8. Schönhofer B, et al. Intensive Care Med 2002; 32:908-916 Survival of mechanically ventilated patients admitted to a specialised weaning center
  • 9. Contents Background ICU-associated issues influencing QoL QoL after discharge Strategies to improve QoL after prolonged MV Some open questions
  • 10. QoL-relevant issues in the ICU Relatives Sedation & analgesia Environment & sleep Staff Nurse Physicians Psychololgical & Spiritual care Delirium Pharmaco- therapy Mechanical ventilation
  • 11. Rotondi AJ, et al. CCM, 2002; 30:746 n=150 patients 50 did not remember 100 did remember Patient‘s recollections of stressful experiences while receiving PMV in an ICU • Remembered ETT (n=75) – Pain and discomfort: 68% – Anxiety about ETT: 68% • Remembered ICU stay (n=97) – Feeling fearful: 44% – Being in pain: 39% – Feeling terror or panic: 32%
  • 12. Physical deconditioning and muscle weakness after PMV De Jonghe et al, JAMA 2002; 288: 2859-2867
  • 13. Contents Background Disease- and ICU-associated issues influencing QoL QoL after discharge Strategies to improve QoL after prolonged MV Some open questions
  • 14. SF-36 Ware, Boston 1993 SIP Bergner, Med Care 1981 NHP Hunt, Soc Sci Med 1981 Uses 36 items to measure eight QOL domains: • physical functioning • role limitations due to physical problems • bodily pain • general health perceptions • energy/vitality • social functioning • role limitations due to emotional problems • mental health Uses 136 questions to evaluate twelve QOL domains: • work • recreation • emotional behavior • alertness • home management, • sleep • body care • eating, • ambulation • mobility • communication, • social interaction Evaluates subjective functional status with 38 yes/no statements in six domains: • physical mobility • pain • sleep • energy • emotional reactions • social isolation
  • 15. MV < 96 h Survival and quality of life: Short-term vs. long- term ventilator patients Douglas SL, et al. CCM 2002;30:2655-62 MV > 96 h better  QoL  worse
  • 16. 2-Months Mortality and Functional Status of Critically Ill Adult Patients Receiving PMV • 817 patients • Mean duration of MV: 9 days • At 2 months: – Mortality 43% – Functional status deteriorated & declined – 35% of survivors were at risk for clinical depression – 78% of survivors had a caregiver Chelluri L, et al. Chest 2002; 121: 549-558
  • 17. Stressful memories and psychological distress in MV adult ICU patients – a 2-month follow-up study • 313 Patients, intubated > 24 h • 2-months follow up : 226 Patients • High symptom levels of PTSD: 8,4 % • Conclusion: Extremely stressful experiences on the ICU are associated with Posttraumatic stress disorder (PTSD) • Risk factors: – Female sex – Agitation – Extreme fear during ICU stay Samuelson KA, et al Acta Anaesthesiol Scand. 2007; 51:671-8
  • 18. Posttraumatic stress disorder following intensive care: a hypothesis generating study of diversity in care Jones C, et al. Intensive Care Med. 2007;33:978-985 Physical restraint Sedation Previous psychological problems PTSD Delusional memories
  • 19. PF: physical functioning RP: role physical SF-36 • Quality of life of ARDS survivors remains persistently lower than in healthy population 1 to 3 yrs after ICU discharge
  • 20. FVC (% predicted) 6-minute walk (% predicted) Return to work (%) 117 ARDS pts 21 days MV Herridge et al, NEJM 2003; 348: 683-693
  • 21. Functional outcome in PMV depends on diagnosis! Quality of life in survivors after PMV Chatila, et al CCM 2001; 737-742 better  QoL  worse 44 ALI patients 25 days MV in ICU 14 days MV in VRU Sickness Impact Profile (SIP)
  • 22. > 6 mo discharged from ICU • MV > 14 d • 93% successfully weaned • 51% NIV Health-related quality of life after PMV Euteneuer et al, Respir Med 2006;100:477-486
  • 23. Health-related quality of life after PMV Respir Med 2006;100:477-486 worse  QoL  better
  • 24. SF-36 Score (0 = worst) All NMD COPD mixed Thoracic- restrictive PCS = Physical Component Summary MCS = Mental Component Summary **P < 0,01 *P < 0,05 compared to standard group ** ** ** *** * Health-related quality of life after PMV Respir Med 2006;100:477-486
  • 25. ARDS Curr Opin Crit Care 200%; 11: 369-375
  • 26. Hopkins RO, et al. Chest 2006;130:869-878 Long-term neurocognitive function after critical illness. Premorbid characteristics Age / Gender / Disease / Pre-existing Cognitive impairments Critical Illness / ICU treatment Sedatives + Analgetics Hypotension Hypoxemia Glucose dysregulation Metabolic derangements Development of delirium Long term Neurocognitive impairments ICU Syndrome ICU Psychosis Postoperative delirium
  • 27. 15 ARDS pts, 15 pts controls ( age & sex matched) 47 days MV CT scan 16 days after ARDS onset Control ARDS At 1 yr, 50% pts with significant memory impairment Hopkins et al, Brain Injury, 2006; 20: 263-271 Brain atrophy and cognitive impairment
  • 28. 74 ARDS pts 28 days MV Neurocognitive disorders • Verbal memory • Attention/Concentration 2 yrs after ICU discharge Hopkins et al, AJRCCM 2005; 171; 340-347 worse  QoL  better
  • 29. Mob : Physical mobility; Soc: Social isolation; Emo: emotional reaction 37 days MV 3 yrs after ICU discharge Combes et al, CCM 2003; 31 better  QoL  worse French Nottingham Health Profile score
  • 30. 46 ARDS pts 26 days MV 8 yrs after ICU discharge Severe posttraumatic stress disorder (23% pts) Intense fear – helplessness – anxiety persisting reexperiencing • Related to the duration of MV, but not to the ARDS severity • Process of traumatization - weaning itself - threatened respiration without mechanical support - feeling of suffucation Kapfhammer et al, Am J Psychiatry 2004; 161: 45-52
  • 31. Location after discharge from weaning unit Schönhofer et al, Intensive Care Medicine 2002; 28: 908 0 10 20 30 40 50 60 Home Hospital Nursing home Rehab [%]
  • 32. Nursing Home (n=16) Rehab (n=11) Home (n=17) p Physical SIP score 52,2 51,9 29,4 .004 Psychosocial SIP score 37,4 21,6 21,3 .016 Hospital Readmission among Long-term Ventilator Patients Douglas SL, et al. CHEST 2001;120:1278-1286
  • 33. Contents Background Disease- and ICU-associated issues influencing QoL QoL after discharge -long-term ICU-stay -ARDS -PTSD Strategies to improve QoL after PMV Some open questions
  • 34. ICU Care Medical Nursing Early Rehab Respiratory Discharge planning Respir care Physician Social Services Relatives Post acute Setting Home Nursery home Rehabilitation LTMV Facility Strategies to improve QoL after PMV Quality of life
  • 35. [...] This suggests the potential for improved symptom management, which could contribute to a less stressful ICU stay and improved patient outcomes. Patient‘s recollections of stressful experiences while receiving PMV in an ICU Rotondi AJ, et al. CCM, 2002; 30:746
  • 36. Time(hours) ProbabilitytoremainunderMV 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 0 100 200 300 400 500 600 700 800 900 1000 1100 p<0.0001 Vitacca M. Am J Respir Crit Care Med 2001; 164: 225-230 Weaning centre: High expertise in weaning problems
  • 37. Davidson JE, et al. CCM 2007; 35:605-622 [...] Many people have strong attachments to their pets... The patient-centered ICU: American College of Critical Care Medicine Task Force 2004-2005.
  • 38. Effects of music therapy on anxiety in ventilator- dependent patients Music therapy is an effective intervention in decreasing anxiety in ventilator-dependent patients and its use should be incorporated into the care of mechanically ventilated patients. Heart Lung 2001; 30: 376-87
  • 39. Admission Discharge Motor strength p Upper limb score 1,9 3,6 < 0,001 Lower limb score 1,5 2,7 < 0,001 FIM score supine to sit 1,0 3,0 < 0,001 Sit to stand 1,0 3,0 < 0,001 CCM 2005; 39: Impact of whole-body rehabilitation in patients receiving PMV Martin UJ, et al. CCM, 2005; 33:2259-65
  • 40. For pts ventilated for > 3 days Disease management program Team: - advanced practice nurses - a geriatrician - pulmonologist Ongoing care coordination Family support Teaching Monitoring of therapies Fewer days of rehospitalization Less depression in caregivers Cost savings for the hospital Daly et al, Chest 2005; 128: 507-517
  • 41. Contents Background Disease- and ICU-associated issues influencing QoL QoL after discharge -long-term ICU-stay -ARDS -PTSD Strategies to improve QoL after prolonged MV Some open questions
  • 42. Is there an effect of burnout syndrome of the staff on patints‘ QoL after PMV ? Embriaco, et al. AJRCCM 2007; 175:686-692 Poncet, et al, AJRCCM 2007; 175:698-704 Burnout No burnout
  • 43. Is there an effect of relatives with Post-traumatic Stress Symptoms on pats‘ QoL after PMV ? PTSS in Family Members of ICU Patients Azoulay, et al. AJRCCM 2005;171: 987-94 all (284) not enough time info incomlete Info too complex
  • 44. • After PMV survivors tend to have physical and mental impairments in the long-term • Minority is discharged directly to home and often hospital readmission is required Conclusions (I)
  • 45. Conclusions (II) • A post-PMV follow-up is needed: Assess patients‘ level of anxiety and perception of fear Identify patients at risk of psychological distress • Professional discharge management and care after ICU Length of time may vary with patient‘s condition • Anti-PTSD and -burnout strategies also for staff and relatives

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