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Persistent Critical Illness

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While much of resuscitation focuses on the dramatic early minutes to hours of critical illness, many patients stay for days or weeks in the ICU. This talk will ask: why do patients get stuck in the ICU, and what might we do better to improve their care?

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Persistent Critical Illness

  1. 1. This work does not necessarily represent the views of the U.S. Government or Department of Veterans Affairs 3 Short Stories of Persistent Critical Illness Theodore J. Iwashyna, MD, PhD University of Michigan Ann Arbor VA Center for Clinical Management Research twitter: @iwashyna 29 June 2017 – dasSMACC
  2. 2. Act 1, in which I meet Ms. Perci Jones, and do not recognize her Act 2, in which Dr. Viglianti shows that Ms. Jones is not alone Act 3, in which Ms. Jones travels the world Epilogue, in which I tell you what I think I have learned so far
  3. 3. Ms. Perci Jones [pseudonym] is a 60 year old previously well-compensated cirrhotic Day 1: Biliary septic shock, failed ERCP, PTC tube placed Day 2: Kidneys fail, CRRT started Day 3: Florid ARDS, intubated Day 4: diarrhea, c. diff Day 5: off pressors! Day 6: exubated! Day 7: IHD run, shock, back on pressors …
  4. 4. Ms. Perci Jones [pseudonym] is a 60 year old previously well-compensated cirrhotic Day 1: Biliary septic shock, failed ERCP, PTC tube placed Day 2: Kidneys fail, CRRT started Day 3: Florid ARDS, intubated Day 4: diarrhea, c. diff Day 5: off pressors! Day 6: exubated! Day 7: IHD run, shock, back on pressors … Beduneau et al (2017) Am J Resp Crit Care Med 195:772; see also the ProVENT model for prognostication, e.g. Carson et al (2012) CCM 40:1171.
  5. 5. Van den Berge (1998) Verhandelingen - Koninklijke Academie voor Geneeskunde van Belgie 60:487. Ms. Perci Jones [pseudonym] is a 60 year old previously well-compensated cirrhotic Day 1: Biliary septic shock, failed ERCP, PTC tube placed Day 2: Kidneys fail, CRRT started Day 3: Florid ARDS, intubated Day 4: diarrhea, c. diff Day 5: off pressors! Day 6: exubated! Day 7: IHD run, shock, back on pressors …
  6. 6. Nelson et al (2010) Am J Resp Crit Care Med 182:464. Ms. Perci Jones [pseudonym] is a 60 year old previously well-compensated cirrhotic Day 1: Biliary septic shock, failed ERCP, PTC tube placed Day 2: Kidneys fail, CRRT started Day 3: Florid ARDS, intubated Day 4: diarrhea, c. diff Day 5: off pressors! Day 6: exubated! Day 7: IHD run, shock, back on pressors …
  7. 7. Existing literature is all about patients who were stably stuck. Caring for Ms. Jones was all about finding new problems. Ms. Perci Jones [pseudonym] is a 60 year old previously well-compensated cirrhotic Day 1: Biliary septic shock, failed ERCP, PTC tube placed Day 2: Kidneys fail, CRRT started Day 3: Florid ARDS, intubated Day 4: diarrhea, c. diff Day 5: off pressors! Day 6: exubated! Day 7: IHD run, shock, back on pressors … @anzic_rc @BellomoRinaldo
  8. 8. Act 1, in which I meet Ms. Perci Jones, and do not recognize her Act 2, in which Dr. Viglianti shows that Ms. Jones is not alone Act 3, in which Ms. Jones travels the world Epilogue, in which I tell you what I think I have learned so far
  9. 9. Among patients who spend a long time in the ICU, how common are new, late organ failures? That is, how unusual was Ms. Jones’ continuing development of new forms of instability? Liz Viglianti U Michigan
  10. 10. Define a new, late organ failure Liz Viglianti U Michigan Mike Sjoding U Michigan @msjoding ICU LOS >14 days (n=130) Excluded 80 patients: • Outside Transfers (n=39) • Prior ICU admission (n=38) • Other (n=3) 50 patients, with 520 patient-days
  11. 11. 0% 10% 20% 30% 0 1 2 3 4 Total Number of New Organ Failures, ICU Day 4+ Liz Viglianti U Michigan
  12. 12. 0% 10% 20% 30% 0 1 2 3 4 Total Number of New Organ Failures, ICU Day 4+ Liz Viglianti U Michigan
  13. 13. 0% 10% 20% 30% 0 1 2 3 4 Total Number of New Organ Failures, ICU Day 4+ Liz Viglianti U Michigan Ms Jones!
  14. 14. Act 1, in which I meet Ms. Perci Jones, and do not recognize her Act 2, in which Dr. Viglianti shows that Ms. Jones is not alone Act 3, in which Ms. Jones travels the world Epilogue, in which I tell you what I think I have learned so far
  15. 15. 0% 10% 20% 30% 0 1 2 3 4 Total Number of New Organ Failures, ICU Day 4+ Formalizing a “persistent critical illness” hypothesis: there is a point in the ICU stay beyond which ICU-admission diagnosis and severity of illness in the first 24 hours no longer differentiates patients regarding their probability of in-hospital death.
  16. 16. Iwashyna, Hodgson, Bailey, Pilcher, van Lint, Chavan, Bellomo (2016) Lancet Respiratory Medicine Acute Characteristics ICU Admission Diagnosis ICU Admission Physiology RRT in 24 hours Prior to ICU Cardiac Arrest Prior to ICU Time Awaiting ICU Bed Antecedent Characteristics Age Demographics Comorbidities (sparse here) Hospital Characteristics Time of Year
  17. 17. Iwashyna, Hodgson, Bailey, Pilcher, van Lint, Chavan, Bellomo (2016) Lancet Respiratory Medicine Hospital Outcome 10 or Fewer Days More Than 10 Days Death 90,323 (9∙2%) 12,625 (24∙4%) Discharge to: Home 758,552 (77∙7%) 23,698 (49∙9%) Rehabilitation or Long-term Care 68,584 (7∙0%) 8,834 (17∙2%) Other Hospital 59,627 (6∙1%) 6,082 (11∙8%) 51,509 patients who stayed 10 days or more: 5.0% of all ICU patients 32.8% of all ICU bed-days
  18. 18. Slide courtesy of Kathy Rowan, representing unpublished work by her and David Harrison. @KathyRowan101 and @DavidHarrison80
  19. 19. Act 1, in which I meet Ms. Perci Jones, and do not recognize her Act 2, in which Dr. Viglianti shows that Ms. Jones is not alone Act 3, in which Ms. Jones travels the world Epilogue, in which I tell you what I think I have learned so far
  20. 20. Persistent Critical Illness (a preliminary definition) those patients whose current reason for being in ICU is now more related to their ongoing critical illness than their original reason for ICU @anzic_rc
  21. 21. Fundamentally Random Structured Cascades of Failures Unstable Homeostasis
  22. 22. 1≠10
  23. 23. Less cross-coverage = More Death (all else equal) More cross-coverage Sometimes a fresh look can be really good for you. See Amaral (2014) AJRCCM 189:1395.
  24. 24. Persistent Critical Illness (a preliminary definition) those patients whose current reason for being in ICU is now more related to their ongoing critical illness than their original reason for ICU I would love to hear your thoughts twitter @iwashyna or email @anzic_rc @msjodingLiz Viglianti Shameless plug: interested in Implementation Science? Check out our new 3-year training program at tactical.med.umich.edu
  25. 25. It is our hypothesis that there exists a substantial and growing group of patients who are ICU-dependent, in the sense that they are are unable to live for more than a few days outside of intensive-care-like services whose current problems are driven by their ongoing cascading critical illnesses rather than their original ICU admitting diagnosis who account for a substantial portion of our bed-days for whom we have little specific expertise in promoting their recovery (as opposed to continuing their resuscitation) but who are not immutably fated to such limbo, but rather whose care we could improve both via improved ICU patient selection but also by changing care & communication practices in the ICU

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