This document discusses outcomes for patients after critical illness and intensive care unit (ICU) stays. It summarizes that ICU treatment is associated with excess mortality for up to 15 years after discharge. Specifically for ARDS survivors, physical quality of life remains low. It also notes that post-traumatic stress disorder and cognitive decline are common after ICU stays. The document provides details on specific physical impairments patients may face, as well as non-physical issues like pain, post-traumatic stress disorder, and cognitive decline.

1. Jozef Kesecioglu
Quality of life after ICU in different patient populations

2. Possible outcomes after critical illness

3. Basics for predicting outcomes
“Prediction is very difficult, especially if it's about the future”
Niels Bohr

4. Basics for predicting outcomes
“Prediction is very difficult, especially if it's about the future”
Niels Bohr

5. Basics for predicting outcomes
“Prediction is very difficult, especially if it's about the future”
Niels Bohr

6. Mortality
4 phases of mortality
• ICU mortality
• Hospital mortality
• After hospital mortality (phase 1)
– With excess mortality
• After hospital mortality (phase 2)
– Without excess mortality

7. 4 phases of mortality
Niskanen 1996Flaatten, 2010

8. • 22,298 patients from one 22 bed ICU
• follow-up 1-16 yrs by linking ex-patients to Western Australia Death Register
• Risk of death after 15 yrs SMR 2.01 compared to general population
• Determinants of mortality after hospital discharge:
– age
– peak number of organ failures
– ICU primary diagnosis
– comorbidity
Crit Care Med 2008; 36:1523–1530

9. Crit Care Med 2008; 36:1523–1530

10. Crit Care Med 2008; 36:1523–1530

11. Outline
• Physical impairments after ICU
• Non-physical impairments after ICU

12. Outline
• Physical impairments after ICU
• Non-physical impairments after ICU

13. Functional status after surviving ICU
• Review of 16 articles including 3247 elderly ICU survivors
• Follow-up 3 to 66 months
• Outcome: health related quality of life (HRQOL)
Hennessy, Chest 2005;127; 1764-1774

14. Functional status after surviving ICU
• Huge differences between patients, depending on ICU admission
diagnosis
• Functional status is already lower before ICU admission
• 10 of the 16 studies demonstrated that patients were satisfied, or that
there was no change from premorbid HRQOL.
• In a cohort of patients 85 years of age, 69% would agree to undergo
intensive therapy again if it were needed.
Hennessy, Chest 2005;127; 1764-1774

15. Specific physical problems
Herridge, NEJM 2011; 364:1293-304
• 109 survivors of ARDS
• multiple evaluations until 5-y follow-up

16. Herridge, NEJM 2011; 364:1293-304
SF-36 Mental (MCS) and Physical (PCS)
Functional status after surviving ICU

17. Specific physical problems
Respiratory problems
• Normal or near-normal volumetric and spirometric test results
• Few pulmonary symptoms
• Sequelae from tracheotomies:
– surgery for tracheal stenosis (4 pts)
– cosmetic surgery (6 pts)
Herridge, NEJM 2011; 364:1293-304

18. Specific physical problems
Herridge, NEJM 2011; 364:1293-304
6-minute walk test

19. Specific physical problems
Weight loss
Herridge, NEJM 2003;348:683-93

20. Specific physical problems
Muscle weakness
• review of 36 studies including 263 patients with severe muscle weakness at
discharge
– 68% makes good recovery
– 28% has severe disability impeding independent walking after 3 - 6
months
• risk factors:
– APACHE, SAPS, SOFA
– female sex (OR 4.7)
…
Latronico, Curr Opin Crit Care 2005;11:381-90

21. Specific physical problems
Sexual function
• Sexual function in ICU survivors more than 3 years after major trauma
• 124 male patients
• I.I.E.F. (International Index of Erectile Function):
– 50% sexual function unchanged
– 41% sexual function impaired
– 9% sexual function better than preinjury status
Ulvik, Intensive Care Med 2008;34:447-53

22. Outline
• Physical impairments after ICU
• Non-physical impairments after ICU

23. Pain
• 52 survivors of ICU with LOS > 48 hrs
• 28% had chronic pain at 6 month follow-up
• More ventilator hours and longer hospital LOS increased the risk of
chronic pain
Boyle. Aust Crit Care. 2004;3:104-6

24. DSM IV definition of PTSD
• A potentially debilitating psychiatric condition that develops as the result
of being exposed to a traumatic occurrence, characterized by
symptoms in 3 domains:
– Symptoms of re-experiencing (for example nightmares and
flashbacks).
– Symptoms of avoidance (for example efforts to avoid
conversations).
– Symptoms of increase arousal (for example, sleep disruption and
hyper-vigilance).
Post traumatic stress disorder

25. DSM IV definition of PTSD
• These symptoms must meet two criteria:
– Symptoms must cause significant impairment in social or
occupational functional domains.
– Symptoms must be present for at least 1 month after the traumatic
event.
Post traumatic stress disorder

26. Post traumatic stress disorder
• 920 medical ICU patients from 16 studies
• Incidence 5 – 63%
• Stress factors included awareness during painful procedures, a sense of
helplessness, loss of control, and an imminent threat of death
Jackson. Crit Care. 2007;11(1):R27

27. Traumatic event
No. of
studies
Range of prevalence
estimates
Rape >50 14%–80%
Natural disaster 86 5%–60%
Motor vehicle accident >100 7.6%–34%
Combat in Vietnam >100 1.8%–15%
ICU 16 5%–63%
Post traumatic stress disorder
Jackson. Crit Care. 2007;11(1):R27

28. PTSD risk factors
• ICU length of stay (longer duration)
• Length of mechanical ventilation
• Greater levels of sedation
• Female gender*
• Younger age*
• Pre-existing psychiatric history*
* established risk factors identified in the general PTSD literature
Jackson. Crit Care. 2007;11(1):R27
Post traumatic stress disorder

29. Post traumatic stress disorder
• 352 survivors of ICU stay > 72 hrs
• Randomized to receiving diary or no diary one month after discharge
• PTSD measured at 3 month follow-up
– PTSD intervention group 5%
– PTSD control patients 13% (P = 0.02)
Jones. Crit Care. 2010;14(5):R168

30. Examples from 1 year follow-up UMC Utrecht
• “Now I know what waterboarding is”
• “I have continuous bad memories. Ik could not talk and most of the
nurses could not lip read. I felt powerless”
Post traumatic stress disorder

31. Cognitive decline following ICU

32. Systematic review
• 10 studies
• neuropsychological tests to measure cognitive function
• mean sample size 45 patients per study

33. "Neurocognitive impairments are extremely common in ICU
survivors":
– 70% at hospital discharge
– 45% at 1 year
"The studies used a very conservative definition of
cognitive dysfunction"

34. Hopkins R O , Jackson J C Chest 2006;130:869-878
A possible explanatory
model of neurocognitive
impairments among ICU
survivors.

36. Methods
• Prospective cohort study from 1994 to 2007
• 3000 subjects > 65 y without baseline dementia
• Cognitive Ability Screening Instrument (CASI) every 2 y
(quantitative assessment of attention, concentration, orientation, short-term
memory, long-term memory, language ability, visual construction, list
generating fluency, abstraction, and judgment)
• Outcome measures: CASI score and dementia

37. Results
• Mean follow-up 6 y
• 41 subjects had had critical illness hospitalization
• 5 of these 41 patients had developed dementia
• Hazard ratio for dementia 2.3 after critical illness (p=0.09)
• CASI 2 points lower after critical illness (p=0.05)

38. Among a cohort of older adults without dementia at baseline, those who
experienced acute care hospitalization and critical illness hospitalization had
a greater likelihood of cognitive decline compared with those who had no
hospitalization

39. Discussion: Mechanism for the association is uncertain:
• Critical illness may be a marker for cognitive dysfunction,
or
• Critical illness may be the cause of cognitive dysfunction

40. JAMA 2010;304(16):1787-94

41. JAMA 2010;304(16):1787-94
Participants from the Health and Retirement Study
• 9,223 underwent repeated neuropsychological testing
• 5,031 were hospitalized
– 516 surviving severe sepsis (mean age 77 yrs)
– 4,517 surviving without episode of severe sepsis

42. JAMA 2010;304(16):1787-94
Participants from the Health and Retirement Study
• 9,223 underwent repeated neuropsychological testing
• 5,031 were hospitalized
– 516 surviving severe sepsis (mean age 77 yrs)
– 4,517 surviving without episode of sever sepsis
– OR for cognitive decline after sepsis: 3.34 (1.53 - 7.25)
– OR for cognitive decline control group: 1.15 (0.80 - 1.67)

43. Conclusions
• ICU treatment is associated with excess mortality up to 15 yrs after
discharge
• in ARDS survivors, the physical component of health related quality of life
remains low
• Post traumatic stress disorder and cognitive decline after ICU is common

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ESICM 28th Annual Congress