Long-term effects of critical illness

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  • When do they occur? How often do they occur? How long do they last?
  • ½ of deaths occur in hospitals
    4.4 million patients/yr
    Mortality 10 – 20% (500,000 die/year)
    7500 ICU in USA
  • Use more resources
  • Heterogeneity of diseases – mostly studied ARDS – can be applied to other populations
  • Severe ARF patients – 5-year survival (5 centers)
    Follow >1000 patients enrolled in the SUPPORT trial-Study to understand preference and progrnosis for outcomes and risks of treatment
    Overall survival after ICU d/c in 5 yrs: 65-70%
    Increased mortality in ICU survivors compared to others in first 2-3 years, then levels off.
    Mortality for medical ICU patients = higher than surgical ICU patients
    Mortality = 3.5X that of general population
  • 6-year mortality & QoL in ICU patients with COPD (86 ICUs in spain)
  • SAPS score=simplified acute physiology score (severity & organ failure scores)
  • Netherlands, hatched bars = non-survivors, filled bars =survivors
    SAPS score and age – determinants of mortality
    Other studies that showed age/severity of illness increasing ICU mortality
  • ARDS patients lose appox. 20% of lean body muscle mass after discharge
    Healthy volunteers – require~1 yr to recover mass after prolonged starvation
    Significant energy & protein deficit
    Mechanical swallowing difficulties: from tracheostomy sites
  • CIP: prevalence: 70%; primary axonal degeneration of motor & sensory fibers; ?steroids, paralytics (no evidence)
  • Low DLCO – commonest abnormality seen (mild)
    Most improvement in 1st 3 – 6 months
    Herridge et al study – 109 ARDS patients- PFT”s plateau after 3-6 months
  • Gas exchange – normal at rest, mild hypoxia during exercise; no-one had required home oxygen
    CT: coarse reticular pattern – most common anteriorly
  • Anterior pattern
  • Tethering of skin to trach site – distressing sensation
  • Myopathy: type 2 fiber atrophy – from prolonged immobilizatoin & disuse
    HO: deposition of para-articular ectopic bone, assd with trauma, burns, paralysis, ARDS (due to prolonged paralysis). Hips, shoulders, knees affected. Pathophysiology: osteoblasts grow in soft tissue next to affected joint. Can cause disfigurement.
    ICU patients- prolonged paralysis/sedation – high risk; incidence (3%)- immobilize large joint, prevent recovery. Tx surgery
  • Research: 10 cohort studies only
    Underrecognized – many patients not even being evaluated
    Earlier reports = 1/3 of patients
  • REVIEW article of current literature
    ARDS: 70% NCE @ d/c, 45% @ 1 year (almost 100% in some studies upon ICU d/c)
    Memory = most common cognitive function affected
  • More striking NCE on geriatric patients with pre-existing NC impairment
    Elderly: more likely to have comorbidities (i.e. dementia-37%)
    Most studies – excluded pts with preexisting neurocognitive impairments
    May persist for up to 6 years
  • Manifestation of delirum – quiet withdrawal to violent
    Hypnagogic state – between sleep and wakefulness (confusion between fantasy & memory
    Surgical vs. medical ICU – less delirium with surgical patients
    b/c manifectations vary – Dx difficult
    Very little know about long-term effects of delirium
    True incidence of delirium = unknown
  • Dissociative symptoms: depersonalization, derealization, dissociative amnesia
    PTSD, depression- correlated with duration of sedation, presence of adverse events in ALI patients OR markers of prolonged stay
    PTSD: occurs in patients experiencing a traumatic event. Invokes fear, horror, helplessness.
    PTSD – may be associated with sedation
    20-30% have amnesia
    ½ - had dreams and nightmares
  • Cognitive impairements – likely to effect memory and pt’s compliance and understanding with medications and rehab and discharge instructions.& appointments
    This study – landmark study – 1st study to look at cognitive outcomes in ARDS patients/survivors
    Used sensitive neuropsychological and neurocognitive testing – may be missed on general clinical examination
  • Unrealistic expectations of recovery
    SUPPORT – study understand prognosis and preferences for outcomes and risks for treatment
  • SUPPORT trial
    - 20% of patients reported a family member who quit work,
    - 29% lost major source of income,
    - 31% lost majority of family savings
  • Medical outcomes short form 36
  • Swedish study
  • 368 = ICU survivors
    Hopkins et al study: @ 1 year, 44% of ARDS pts did not return to work.
    Trauma, ARpF = worse
    QoL influenced by ICU diagnosis
    Other factors: pre-existing disease
  • MC study, Canada & Germany
  • ARDS survivors have significant decrease in QoL and is associated with impairments in PFTs
  • Pittsburgh group – 2 months
  • SF-36: instrument, validated in the ICU – 36 questions covering 8 domains
    Age = no consistent predictor of worse ICU QoL; Age – mixed effect on QoL outcomes
    Bias: higher expectations in young
    Most elderly patients – returned home & to pre-hospitalization status
  • Nursing perspective
    Can mobilize even during mechanical ventilation
  • Sleep disturbances – mostly lighter stages of sleep, frequent awakenings
    Sleep environment: consistent sleep-rest periods, uninterrupted blocks
  • Discharge planning – not done in canada, USA, some in Australia, Europe
    Liaison nurse: oversee transfer, followup, determine level of care needed, educational and emotional support, mostly in Europe and Australia
    Preparing for home: booklets, information, trach and wound care
  • Mean number of vent days: 4.7
    Chronically critically ill: mech. Vent. > 21 days
    Vent rehab units: less cost of care (nursing expertise & #)
  • 50-90% survive to discharge
  • 46 patients on chronic vent for mean 45 days – 2 years later
  • #2 – because ICU patients have become accustomed to being in a less healthy state. This may also be because they compare post-ICU state of health to pre-ICU state of health, which is usually worse than the general population.
    Survival – not the best outcome measure, poor metric for describing impact of illness.
    Recommendations:
    Good handover
    Patient education & advice on recovery
    Reinforcement of the patients' responsibility for their recovery
    Exercise, rehabilitation, nutrition
    Early recognition and diagnosis of physical & psychological problems
    Communication with PCP
    Follow up for at least 6 months after discharge from hospital
  • Long-term effects of critical illness

    1. 1. Long-term effects of critical illness Khalid F. Almoosa, MD Pulmonary, Critical Care, & Sleep Medicine
    2. 2. Questions • Are there long-term effects of critical illness? • If so, what are they? How often do they occur? How long do they last? • How are these effects related to their experience in the ICU? • How do they affect the patient’s quality of life? • What about the chronically critically ill? ?? ??
    3. 3. Today’s ICU • 55,000 - 90,000 admissions/day1 • 80% of population will require ICU care during lifetime 1 Schmitz et al, 1998
    4. 4. Today’s ICU • Costs of critical care (2001) ~ 1% of GNP ($142 billion)1 – 15% of health care costs - Population demographics – Increasing aging population (13% > 65) • 26% - 51% of ICU population • >60% of ICU days – 40% of patients require mechanical ventilation2 1 Halpern et al, Crit Care Med 1994 2 Esteban et al, AJRCCM 2000
    5. 5. Why are long-term outcomes of critical illness important? • ICU outcomes – traditionally mortality, LoS – Quality of Life -  importance – 6- and 12- month outcomes • Importance: –Rising health care costs –  interest –Can affect provision/type of critical care –Improve patients & caregivers’ anticipation of post-ICU care – improve outcomes –Resource allocation
    6. 6. Components of Long-Term Outcomes  Complexity of factors that influence outcomes (multi-factorial)  Individuality of host response to illness  Interaction between pre-morbid disease & critical illness  Heterogeneity of diseases & ICU practice patterns
    7. 7. Factors affecting recovery from critical illness Recovery Family Psychological Social Physical Employment Pre-morbid state Broomhead & Brett, Critical Care 2002
    8. 8. Components of Long-Term Outcomes  Physical  Neurocognitive and psychosocial  Quality of life  Chronic critical illness
    9. 9. Life expectancy after critical illness
    10. 10. 5-year mortality of ARF survivors Garland et al, CHEST 2004 1000 patients 3X morality 6 – 25% of ICU survivors – die before hospital d/c
    11. 11. Age Quality of Life Determinants of Post-ICU mortality (COPD)
    12. 12. Determinants of Post-ICU mortality • ICU mortality associated with: • Age • Poor chronic health status prior to admission, co- morbidities • SAPS II • Decision to withhold/withdraw life-sustaining treatment – most powerful Azoulay et al, CCM 2003 1385 patients
    13. 13. Survival after 60 days of ICU care • 78 patients, > 60 days stay in ICU • Mortality: 38% Survival: 1 year: 44% 5 years: 33% Venker et al, Anesthesia 2005
    14. 14. Physical effects of critical illness • Nutrition • Neuropathy • Respiratory • Cardiac • Sexual • Other
    15. 15. Physical effects of critical illness • Nutrition • Neuropathy • Respiratory • Cardiac • Sexual • Other • Cachexia – 2% loss of muscle mass per day – 50% during stay Herridge et al, NEJM 2003
    16. 16. Physical effects of critical illness • Nutrition • Neuropathy • Respiratory • Cardiac • Sexual • Other   appetite – weakness, altered taste, depression, dyspnea • Mechanical difficulties
    17. 17. Physical effects of critical illness • Nutrition • Neuropathy • Respiratory • Cardiac • Sexual • Other • Critical illness polyneuropathy – Ischemia of microcirculation – Severity of illness, LOS – Effects: disability, death • Peripheral neuropathy • Entrapment neuropathy – Peroneal nerve – footdrop (3%) – Effect rehabilitation
    18. 18. Physical effects of critical illness • Nutrition • Neuropathy • Respiratory • Cardiac • Sexual • Other • Critical illness polyneuropathy – Ischemia of microcirculation – Severity of illness, LOS – Effects: disability, death • Peripheral neuropathy • Entrapment neuropathy – Peroneal nerve – footdrop (3%) – Effect rehabilitation
    19. 19. Physical effects of critical illness • Nutrition • Neuropathy • Respiratory • Cardiac • Sexual • Other • Dyspnea = common! – Muscle weakness, neuropathy, fibrosis, progression of pre- morbid conditions, psychological 1 Davidson et al, AJRCCM 1999
    20. 20. Pulmonary Function • Most ARDS survivors – abnormal PFT @ discharge but achieve normal spirometry & volumes @ 6 – 12 months1-3 • Some restrictive defect,  DLCO – Significance unclear • ?exercise tolerance 1 McHugh et al, AJRCCM 1994 2 Heyland et al, Crit Care Med 2005 3 Herridge et al, NEJM 2003 Herridge et al, NEJM 2003
    21. 21. Physical effects of critical illness • Nutrition • Neuropathy • Respiratory • Cardiac • Sexual • Other • Persistent CXR changes – CT: Coarse reticular pattern, ground glass
    22. 22. Long-term radiographs changes Desai et al, Radiology 1999 • Related to MV duration • Importance unclear • Most normal @ 1 year
    23. 23. Physical effects of critical illness • Nutrition • Neuropathy • Respiratory • Cardiac • Sexual • Other • ? Postural hypotension • No documented adverse effects of ICU on cardiac function • Sparse data
    24. 24. Physical effects of critical illness • Nutrition • Neuropathy • Respiratory • Cardiac • Sexual • Other • Sexual dysfunction (25%) – No desire – Impotence – Dyspnea – Surgical disfigurement – Concern that sex may precipitate relapse – Improves with time 1 Quinlan, Br J Anesthesia 1998
    25. 25. Physical effects of critical illness • Nutrition • Neuropathy • Respiratory • Cardiac • Sexual • Other • Reduced mobility (6MWT)   muscle mass, weakness – Joint stiffness – Poor balance – Learn to walk, bear weight • Swallowing difficulties – Pharyngeal muscle lack of coordination – Tethering of skin to trach site
    26. 26. Common physical complaints following an ICU stay • Proximal muscle weakness • Myopathy • Heterotopic ossification • Arthralgia, stiffness • Voice changes • Insomnia & sleep problems • Hair loss • Pruritis • Amenorrhoea • Poor cough Broomhead & Brett, Crit Care 2002 Griffiths & Jones, BMJ 1999
    27. 27. Neuropsychological effects of critical illness Cognitive impairment Psychological impairment
    28. 28. Neuropsychological effects • ICU environment – Noisy – Stressful & foreign – Confusing, no day/night – Painful & uncomfortable – Sleepless – Psychoactive drugs – Sickness Traumatic!
    29. 29. Neuropsychological effects of critical illness • Under-recognized • Neglected until recently – Data – brain atrophy in ARDS patients after prolonged ICU stay – Neurological dysfunction during critical illness – contributes to mortality & morbidity • Research = limited
    30. 30. Prevalence of neurocognitive effects • 25% - 100% of ICU survivors! – Greater in specific groups (i.e. ARDS) Hopkins et al, CHEST 2006
    31. 31. Duration of neurocognitive effects • Persist for years • Improve in 6 – 12 months after d/c • Geriatric patients w/ pre-existing NC impairment or dementia • Associations: – APACHE, LoS, LoMV, LoMeds
    32. 32. Neuropsychological effects • Delirium • Affective disorders • Stress disorders • Disorders of cognition • Social & family problems • Incidence: 30% - 80% • Manifestations vary • Associated with amnesia – Distorted memories • Hypnagogic state in ICU – Predisposes to hallucinations & paranoid delusions, nightmares • ? Long-term effects
    33. 33. Neuropsychological effects • Delirium • Affective disorders • Stress disorders • Disorders of cognition • Social & family problems • Anxiety & depression: – 47% - 69% >1 year post ICU* • More likely in those with impaired memory of events * Scragg et al, Anesthesia 2001 * Nelson et al, Crit Care Med 2000
    34. 34. Neuropsychological effects • Delirium • Affective disorders • Stress disorders • Disorders of cognition • Social & family problems • PTSD – 38% – Flashbacks, avoidance of reminiscent situations,  arousal   in ARDS, young • Delusions, amnesia:  risk* • Factual memories:  risk** – Affect QoL, psychosocial functioning * Schelling et al, Crit Care Med 1998 ** Jones et al, Crit Care Med 2001
    35. 35. Neuropsychological effects • Delirium • Affective disorders • Stress disorders • Disorders of cognition • Social & family problems * Hopkins et al, Crit Care Med 1999 • Memory • Executive function • Attention • Intellectual function • Visual spatial
    36. 36. Neuropsychological effects • Delirium • Affective disorders • Stress disorders • Disorders of cognition • Social & family problems • Family members – develop anxiety, depression • Post-D/C = overprotective, unrealistic expectations = frustration • Quit work or major life changes
    37. 37. Consequences of neurocognitive defects   ADLs   quality of life   medical costs • Inability to return to work – ARDS: 32% - 51% not working 1-yr later1,2 – Directly related to neurocognitive dysfunction • Predicts institutionalization in older persons • Require caregiver support 1 Hopkins et al, AJRCCM 2005 2 Herridge et al, NEJM 2003
    38. 38. Quality of life after critical illness
    39. 39. (HR) Quality of life • Multi-dimensional concept – Subjective & objective – Difficult to study • Encompass all areas of patient’s life – Physical, emotional, social, financial, – Preferences, values, perception, altitude – Differ among age, cultures • Current status/knowledge in QoL in ICU patients  poor
    40. 40. SF-36
    41. 41. Quality of Life Orwelius et a, Crit Care Med 2005 2-center 562 patients 6-month f/u Mailed survey
    42. 42. Quality of Life Influential factors • Niskanen et al (CCM 1999) – 368 patients, single center – > 4 days in ICU – Compare to random sample of general pop. – Nottingham Health Profile Lower score = better Diagnosis affects QoL
    43. 43. Quality of Life Changes with time Hopkins et al, AJRCCM 1999 55 ARDS pts
    44. 44. Quality of Life Changes with time • Heyland et al (Crit Care Med 2005) – 73 ARDS survivors – 1 year later – Question: “How would you describe your performance during your everyday life?”
    45. 45. Quality of Life Effects of Pulmonary Function Schelling et al, Int Care Med 2000 Schelling et al (Int Care Med 2000) – correlation of PF & QoL • 50 ARDS survivors, 5.5 yrs after discharge
    46. 46. Quality of Life Caregivers Time of MV 13.9 days Home Rehab/NH/LTAC 49.6% 39.2% Required CG 74.8% Age of CG 52.9 years (76.5% women) CG % working 28.7% CG  work time/stop 30.3% % spend > 4 hr/day > 50% Depression 33.9% 115 patients’ Caregivers Prolonged MV > 48 hrs Im et al, CHEST 2004
    47. 47. Quality of life Summary • Poor in most ICU survivors after d/c – Functionally dependent • Dependent on pre-ICU functional status and admission DX, age, pre-ICU QoL • Improved but still reduced in many patients after 1 year – Approach pre-ICU status • Most satisfied with new state of health
    48. 48. How to improve quality of life • Mobility • Pain & sedation control • Sleep management • Discharge planning
    49. 49. How to improve quality of life • Mobility • Pain & sedation control • Sleep management • Discharge planning - Muscle wasting & weakness - Early - Mechanical ventilation
    50. 50. How to improve quality of life • Mobility • Pain & sedation control • Sleep management • Discharge planning - Psychological effects
    51. 51. How to improve quality of life • Mobility • Pain & sedation control • Sleep management • Discharge planning - Common sleep disturbances - Modify environment
    52. 52. How to improve quality of life • Mobility • Pain & sedation control • Sleep management • Discharge planning - Not done in critical care - ICU transfer sheet - Transfer anxiety - “Weaning” nursing - Liaison nurse - Preparing for home - Communication w/ PCP
    53. 53. Chronic Critical Illness
    54. 54. Chronic Critical Illness • Patients who require continued care in a semi- ICU setting (weeks  months) • Poorly defined group: LOS, mech. vent. • Costs • 5 – 10% of adult ICU admissions • Patients at risk: Trauma, post-op, lung disease, nosocomial PNA – Poor prediction models   admissions to LTAC units, sicker patients, earlier ICU discharges
    55. 55. Chronic Critical Illness Survival from MV patients from LTAC Carson et al, Crit Care Clinics 2002
    56. 56. Chronic Critical Illness Quality of Life • Functional status & QoL after discharge – Better than expected • NH placement, limitations – Most do not survive – Limited data Chatilla et al, Crit Care Med 2001 46 patients 45 days on vent 2 year f/u
    57. 57. Conclusions • Survival AND long-term functional status, QoL • Significant disability &  QoL soon after ICU discharge, but most return to near baseline levels over time • Recommendations to improve long-term outcomes • Need further research
    58. 58. “…For the secret of the care of the patient is in caring for the patient ” - Dr. Francis W. Peabody

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