Longterm effects of critical illness

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Long-term effects of critical illness

• Khalid F. Almoosa, MD
• Pulmonary, Critical Care, Sleep Medicine

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Questions
??
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• 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 patients quality of life?
• What about the chronically critically ill?

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Todays ICU

• 55,000 - 90,000 admissions/day1
• 80 of population will require ICU care during
  lifetime

1Schmitz et al, 1998
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Todays ICU

• Costs of critical care (2001)
• 1 of GNP (142 billion)1
• 15 of health care costs
• Population demographics
• Increasing aging population (13 gt 65)
• 26 - 51 of ICU population
• gt60 of ICU days
• 40 of patients require mechanical ventilation2

1Halpern et al, Crit Care Med 1994 2Esteban et
al, AJRCCM 2000
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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

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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

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Factors affecting recovery from critical illness
Physical
Family
Psychological
Recovery
Employment
Pre-morbid state
Social
Broomhead Brett, Critical Care 2002
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Components of Long-Term Outcomes

• Physical
• Neurocognitive and psychosocial
• Quality of life
• Chronic critical illness

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Life expectancy after critical illness
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5-year mortality of ARF survivors
1000 patients
3X morality
6 25 of ICU survivors die before hospital d/c
Garland et al, CHEST 2004
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Determinants of Post-ICU mortality
(COPD)
Age
Quality of Life
Rivera-Fernandez et al, Crit Care Med 2006
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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
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Survival after 60 days of ICU care

• 78 patients, gt 60 days stay in ICU
• Mortality 38

Survival 1 year 44 5 years 33
Venker et al, Anesthesia 2005
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Physical effects of critical illness

• Nutrition
• Neuropathy
• Respiratory
• Cardiac
• Sexual
• Other

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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
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Physical effects of critical illness

• Nutrition
• Neuropathy
• Respiratory
• Cardiac
• Sexual
• Other

• ? appetite weakness, altered taste, depression,
  dyspnea
• Mechanical difficulties

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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

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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

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Physical effects of critical illness

• Nutrition
• Neuropathy
• Respiratory
• Cardiac
• Sexual
• Other

• Dyspnea common!
• Muscle weakness, neuropathy, fibrosis,
  progression of pre-morbid conditions,
  psychological

1Davidson et al, AJRCCM 1999
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Pulmonary Function

• Most ARDS survivors abnormal PFT _at_ discharge
  but achieve normal spirometry volumes _at_ 6 12
  months1-3
• Some restrictive defect, ? DLCO
• Significance unclear
• ?exercise tolerance

1McHugh et al, AJRCCM 1994 2Heyland et al, Crit
Care Med 2005 3Herridge et al, NEJM 2003
Herridge et al, NEJM 2003
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Physical effects of critical illness

• Nutrition
• Neuropathy
• Respiratory
• Cardiac
• Sexual
• Other

• Persistent CXR changes
• CT Coarse reticular pattern, ground glass

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Long-term radiographs changes

• Related to MV duration
• Importance unclear
• Most normal _at_ 1 year

Desai et al, Radiology 1999
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Physical effects of critical illness

• Nutrition
• Neuropathy
• Respiratory
• Cardiac
• Sexual
• Other

• ? Postural hypotension
• No documented adverse effects of ICU on cardiac
  function
• Sparse data

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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

1Quinlan, Br J Anesthesia 1998
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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

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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
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Neuropsychological effects of critical illness
Cognitive impairment Psychological impairment
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Neuropsychological effects

• ICU environment
• Noisy
• Stressful foreign
• Confusing, no day/night
• Painful uncomfortable
• Sleepless
• Psychoactive drugs
• Sickness

Traumatic!
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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

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Prevalence of neurocognitive effects

• 25 - 100 of ICU survivors!
• Greater in specific groups (i.e. ARDS)

Hopkins et al, CHEST 2006
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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

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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

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Neuropsychological effects

• Delirium
• Affective disorders
• Stress disorders
• Disorders of cognition
• Social family problems

• Anxiety depression
• 47 - 69 gt1 year post ICU
• More likely in those with impaired memory of
  events

Scragg et al, Anesthesia 2001 Nelson et al,
Crit Care Med 2000
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Neuropsychological effects

• PTSD 38
• Flashbacks, avoidance of reminiscent situations,
  ? arousal
• ? in ARDS, young
• Delusions, amnesia ? risk
• Factual memories ? risk
• Affect QoL, psychosocial functioning

• Delirium
• Affective disorders
• Stress disorders
• Disorders of cognition
• Social family problems

Schelling et al, Crit Care Med 1998 Jones et
al, Crit Care Med 2001
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Neuropsychological effects

• Delirium
• Affective disorders
• Stress disorders
• Disorders of cognition
• Social family problems

• Memory
• Executive function
• Attention
• Intellectual function
• Visual spatial

Hopkins et al, Crit Care Med 1999
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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

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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

1Hopkins et al, AJRCCM 2005 2Herridge et al, NEJM
2003
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Quality of life after critical illness
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(HR) Quality of life

• Multi-dimensional concept
• Subjective objective
• Difficult to study
• Encompass all areas of patients life
• Physical, emotional, social, financial,
• Preferences, values, perception, altitude
• Differ among age, cultures
• Current status/knowledge in QoL in ICU patients ?
  poor

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SF-36
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Quality of Life
2-center 562 patients 6-month f/u Mailed survey
Orwelius et a, Crit Care Med 2005
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Quality of Life Influential factors

• Niskanen et al (CCM 1999)
• 368 patients, single center
• gt 4 days in ICU
• Compare to random sample of general pop.
• Nottingham Health Profile

Lower score better
Diagnosis affects QoL
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Quality of LifeChanges with time
55 ARDS pts
Hopkins et al, AJRCCM 1999
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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?

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Quality of Life Effects of Pulmonary Function

• Schelling et al (Int Care Med 2000) correlation
  of PF QoL
• 50 ARDS survivors, 5.5 yrs after discharge

Schelling et al, Int Care Med 2000
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Quality of LifeCaregivers
115 patients Caregivers Prolonged MV gt 48 hrs
Im et al, CHEST 2004
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Quality of lifeSummary

• 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

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How to improve quality of life

• Mobility
• Pain sedation control
• Sleep management
• Discharge planning

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How to improve quality of life

• Mobility
• Pain sedation control
• Sleep management
• Discharge planning

• - Muscle wasting weakness
• Early
• Mechanical ventilation

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How to improve quality of life

• Mobility
• Pain sedation control
• Sleep management
• Discharge planning

- Psychological effects
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How to improve quality of life

• Mobility
• Pain sedation control
• Sleep management
• Discharge planning

• Common sleep disturbances
• Modify environment

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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

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Chronic Critical Illness
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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

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Chronic Critical IllnessSurvival from MV
patients from LTAC
Carson et al, Crit Care Clinics 2002
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Chronic Critical IllnessQuality of Life

• Functional status QoL after discharge
• Better than expected
• NH placement, limitations
• Most do not survive
• Limited data

46 patients 45 days on vent 2 year f/u
Chatilla et al, Crit Care Med 2001
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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

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For the secret of the care of the patient is in
caring for the patient - Dr. Francis W.
Peabody