Long-term effects of critical illness - PowerPoint PPT Presentation

Loading...

PPT – Long-term effects of critical illness PowerPoint presentation | free to download - id: 3c7206-YzRhZ



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Long-term effects of critical illness

Description:

Long-term effects of critical illness Khalid F. Almoosa, MD Pulmonary, Critical Care, & Sleep Medicine Questions Are there long-term effects of critical illness? – PowerPoint PPT presentation

Number of Views:122
Avg rating:3.0/5.0
Slides: 60
Provided by: aitlvideo
Learn more at: http://aitlvideo.uc.edu
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Long-term effects of critical illness


1
Long-term effects of critical illness
  • Khalid F. Almoosa, MD
  • Pulmonary, Critical Care, Sleep Medicine

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

3
Todays ICU
  • 55,000 - 90,000 admissions/day1
  • 80 of population will require ICU care during
    lifetime

1Schmitz et al, 1998
4
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
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
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
Factors affecting recovery from critical illness
Physical
Family
Psychological
Recovery
Employment
Pre-morbid state
Social
Broomhead Brett, Critical Care 2002
8
Components of Long-Term Outcomes
  • Physical
  • Neurocognitive and psychosocial
  • Quality of life
  • Chronic critical illness

9
Life expectancy after critical illness
10
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
11
Determinants of Post-ICU mortality
(COPD)
Age
Quality of Life
Rivera-Fernandez et al, Crit Care Med 2006
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
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
14
Physical effects of critical illness
  • Nutrition
  • Neuropathy
  • Respiratory
  • Cardiac
  • Sexual
  • Other

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
Physical effects of critical illness
  • Nutrition
  • Neuropathy
  • Respiratory
  • Cardiac
  • Sexual
  • Other
  • ? appetite weakness, altered taste, depression,
    dyspnea
  • Mechanical difficulties

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
(No Transcript)
19
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

20
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
21
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
22
Physical effects of critical illness
  • Nutrition
  • Neuropathy
  • Respiratory
  • Cardiac
  • Sexual
  • Other
  • Persistent CXR changes
  • CT Coarse reticular pattern, ground glass

23
Long-term radiographs changes
  • Related to MV duration
  • Importance unclear
  • Most normal _at_ 1 year

Desai et al, Radiology 1999
24
Physical effects of critical illness
  • Nutrition
  • Neuropathy
  • Respiratory
  • Cardiac
  • Sexual
  • Other
  • ? Postural hypotension
  • No documented adverse effects of ICU on cardiac
    function
  • Sparse data

25
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
26
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

27
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
28
Neuropsychological effects of critical illness
Cognitive impairment Psychological impairment
29
Neuropsychological effects
  • ICU environment
  • Noisy
  • Stressful foreign
  • Confusing, no day/night
  • Painful uncomfortable
  • Sleepless
  • Psychoactive drugs
  • Sickness

Traumatic!
30
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

31
Prevalence of neurocognitive effects
  • 25 - 100 of ICU survivors!
  • Greater in specific groups (i.e. ARDS)

Hopkins et al, CHEST 2006
32
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

33
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

34
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
35
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
36
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
37
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

38
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
39
Quality of life after critical illness
40
(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

41
SF-36
42
Quality of Life
2-center 562 patients 6-month f/u Mailed survey
Orwelius et a, Crit Care Med 2005
43
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
44
Quality of Life Changes with time
55 ARDS pts
Hopkins et al, AJRCCM 1999
45
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?

46
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
47
Quality of Life Caregivers
115 patients Caregivers Prolonged MV gt 48 hrs
Im et al, CHEST 2004
48
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

49
How to improve quality of life
  • Mobility
  • Pain sedation control
  • Sleep management
  • Discharge planning

50
How to improve quality of life
  • Mobility
  • Pain sedation control
  • Sleep management
  • Discharge planning
  • - Muscle wasting weakness
  • Early
  • Mechanical ventilation

51
How to improve quality of life
  • Mobility
  • Pain sedation control
  • Sleep management
  • Discharge planning

- Psychological effects
52
How to improve quality of life
  • Mobility
  • Pain sedation control
  • Sleep management
  • Discharge planning
  • Common sleep disturbances
  • Modify environment

53
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

54
Chronic Critical Illness
55
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

56
Chronic Critical Illness Survival from MV
patients from LTAC
Carson et al, Crit Care Clinics 2002
57
Chronic Critical Illness Quality 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
58
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

59
For the secret of the care of the patient is in
caring for the patient - Dr. Francis W.
Peabody
About PowerShow.com