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Thriving, not just surviving after critical illness

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Covering DL vs VL, second gen supraglottics, LMA-as-conduit, Vortex approach and of course SALAD !

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Thriving, not just surviving after critical illness

  1. 1. Thriving – Not Just Surviving Prof Carol Hodgson PhD FACP Deputy Director ANZIC-RC Chair TEAM Study, PREDICT Study and Co-Chair of PHARLAP Management Committee (ANZICS CTG) Specialist Physiotherapist, ICU, The Alfred, Melbourne, Australia
  2. 2. Increasing survival and discharge to rehabilitation after ICU Kaukonen et al, JAMA, 2014
  3. 3. N=155 Surrogate markers: Decreased ICP Decreased therapies for ICP Decreased ICU length of stay
  4. 4. = Alive = Dead Cooper et al (2011) NEJM 364:1493. Decompressive Craniectomy: Standard Care:
  5. 5. = Full Recovery = Significant Morbidity = Dead Cooper et al (2011) NEJM 364:1493. Decompressive Craniectomy: Standard Care: = Full Recovery = Significant Morbidity = Dead
  6. 6. Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT) RCT. The AVERT Trial Collaboration group Lancet Online: 16 April 2015 The AVERT Trial Collaboration group Lancet Online: 16 April 2015 Favorable outcome measured at 3 months Modified Rankin 0-2 = little or no disability
  7. 7. Thriving – not just surviving 1. Learn from current practice 2. Identify who is at risk 3. Test new strategies
  8. 8. 5 Year Outcome of ARDS Survivors
  9. 9. Increased disability after IMV versus hospitalisation Barnato, AJRCCM, 2011 • Elderly may not chose this • Outcomes were worse than expected by the family and ICU staff ADL Mobility MV MV
  10. 10. Trajectory of recovery Iwashyna AJRCCM, 2012
  11. 11. Physical and mental / cognitive baseline status Acute illness Organ function - impairment Activity - functional limitation Participation - disability Quality of life WHO conceptual model International Classification of Functioning (WHO) World Health Organization. International Classification of Functioning, Disability and Health. Geneva; 2001
  12. 12. ANZ CTG Trials and LTOs Hodgson & Iwashyna,, 2016
  13. 13. Domains SF-36 EQ5D Physical status Psychological status Cognitive status Activities and behaviours Physical zone of comfort & activity Interactions and relationships with others Perceptions & responses to life Personality Appearance Clothing Place of residence Finances Captured by questionnaire Inconsistently / infrequently captured by questionnaire Not captured by questionnaire Conceptualizing HRQoL in Critical Care Lim et al, 2016
  14. 14. Physical and mental / cognitive baseline status Acute illness Organ function - impairment Activity - functional limitation Participation - disability Quality of life WHO conceptual model The Evidence Gap Disability Assessment Iwashyna and Netzer, 2012 Disability Assessment - environmental factors - personal factors
  15. 15. www.improveLTO.com 16 Contact us: improveLTO@jhmi.edu
  16. 16. 17 www.improveLTO.com improveLTO@jhmi.edu
  17. 17. Core outcome measures for research in ARF Needham et al, AJRCCM, 2017 Core Domains Tool Time (minutes) Cost AUD Life satisfaction EQ5D (3L or 5L) 5-10 20 Pain EQ5D(3L or 5L) - Anxiety and depression HADS 10-15 30 Post traumatic stress IES-R 10-15 30 Tools that reached consensus: $50 - 100 AUD per patient
  18. 18. Thriving – not just surviving 1. Learn from international practice 2. Identify who is at risk 3. Test new strategies • Multidisciplinary co-ordination • Communication – with patients / the ICU team / rehabilitation / primary health • Rehabilitation – early?
  19. 19. Disability after ICU Hodgson et al, ICM, 2017
  20. 20. Demographic and hospital data N=262 Survivors Age, mean ± SD 59 ± 16 Male, % (N) 67 (175) APACHE II, mean ± SD 19 ± 8 Total number of comorbidities, median [IQR] 0 [0-1] Diagnosis, % (N) Cardiogenic shock / ischemia / arrhythmia 41 (107) Acute respiratory failure 15 (38) Gastrointestinal disease 10 (27) Neurological disease or seizure 7 (17) Trauma 16 (43) Days of Mechanical Ventilation, median [IQR] 3 [2-6] ICU LOS, Days, median [IQR] 7 [4-11] Hospital LOS, Days, median [IQR] 23 [14-45]
  21. 21. Results – WHODAS at 6 months • Disability was highest in the areas of physical activity e.g. walking Disability WHODAS - 25%
  22. 22. Multivariable analysis: Predictors of disability Predictor Odds Ratio P Value History of anxiety / depression 1·65 [1·22, 2·23] <0·001 Separated or divorced 2·88 [1·35, 6·08] <0·001 Mechanical ventilation days 1·04 [1·01, 1·08] 0·027 No difference: age, gender, pre-ICU HRQoL and work status, APACHE II, comorbidities, diagnoses, GCS, RRT, sepsis and LOS Disability-free survival was 57%
  23. 23. Differences in health status (EQ5D-5L) at 6months No problem No Disability (N=197) Disability (N=65) P Mobility, N (%) 53% 15% <0.001 Personal Care, N (%) 82% 43% <0.001 Usual Activities, N (%) 59% 14% <0.001 Pain, N (%) 55% 26% <0.001 Anxiety and depression, N (%)* 74% 32% <0.001 Utility Score, mean ± SD 0.77 ± 0.26 0.50 ± 0.26 <0.001
  24. 24. Return to Work • One third had not returned to work (if previously working) • Predictors of being unemployed due to health No difference: age, gender, pre-ICU HRQoL, marital status, depression, APACHE II, comorbidities, MV days , GCS, RRT, sepsis Predictor (N=107) Odds Ratio P Value Hospital stay, days 1·05 [1·02, 108] <0·01 GCS 0.86 [0.75, 0.99] <0·03 Trauma admission 8.83 [2.56, 30.38] <0·01
  25. 25. Patient Interviews on Recovery Orford et al, unpublished Two themes: 1. Physical recovery was hardest – “even getting dressed was exhausting…. I couldn’t do much” – “I had to start going to the gym …I had no strength” 2. Family support – “I don’t know what I would have done… I needed her help with everything” – “He was my rock…. he took annual leave then long service leave ”
  26. 26. Strategies to improve recovery 1. Learn from international practice 2. Identify who is at risk 3. Test new strategies
  27. 27. Survey of 101 ICU Clinicians Iwashyna, Hodgson, Pilcher, Bailey and Bellomo, CCR, 2015
  28. 28. Early ICU Interventions: Mobilisation – TEAM Sedation – SPICE Nutrition – TARGET
  29. 29. • Diaries • Sleep • Noise • Communication • Family visiting time • Pet therapy • Visits outside • Transition out of ICU
  30. 30. Take home message @chodgsonANZICRC • Disability is prevalent in Australian ICU survivors • Disability impacts physical recovery and survivors require support • We may be able identify & target survivors at increased risk o Separated or divorced o A history of anxiety or depression o Trauma admissions • Clinicians have a strong opinion about how to improve patient outcomes carol.hodgson@monash.edu

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