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  • Slide 1
  • Long-term effects of critical illness Khalid F. Almoosa, MD Pulmonary, Critical Care, & Sleep Medicine
  • Slide 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? ??
  • Slide 3
  • Todays ICU 55,000 - 90,000 admissions/day 1 80% of population will require ICU care during lifetime 1 Schmitz et al, 1998
  • Slide 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% > 65) 26% - 51% of ICU population >60% of ICU days 40% of patients require mechanical ventilation 2 1 Halpern et al, Crit Care Med 1994 2 Esteban et al, AJRCCM 2000
  • Slide 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
  • Slide 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
  • Slide 7
  • Factors affecting recovery from critical illness Recovery FamilyPsychological Social Physical EmploymentPre-morbid state Broomhead & Brett, Critical Care 2002
  • Slide 8
  • Components of Long-Term Outcomes Physical Neurocognitive and psychosocial Quality of life Chronic critical illness
  • Slide 9
  • Life expectancy after critical illness
  • Slide 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
  • Slide 11
  • AgeQuality of Life Determinants of Post-ICU mortality Rivera-Fernandez et al, Crit Care Med 2006 (COPD)
  • Slide 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
  • Slide 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
  • Slide 14
  • Physical effects of critical illness Nutrition Neuropathy Respiratory Cardiac Sexual Other
  • Slide 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
  • Slide 16
  • Physical effects of critical illness Nutrition Neuropathy Respiratory Cardiac Sexual Other appetite weakness, altered taste, depression, dyspnea Mechanical difficulties
  • Slide 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
  • Slide 18
  • Slide 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
  • Slide 20
  • 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
  • Slide 21
  • Pulmonary Function Most ARDS survivors abnormal PFT @ discharge but achieve normal spirometry & volumes @ 6 12 months 1-3 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
  • Slide 22
  • Physical effects of critical illness Nutrition Neuropathy Respiratory Cardiac Sexual Other Persistent CXR changes CT: Coarse reticular pattern, ground glass
  • Slide 23
  • Long-term radiographs changes Desai et al, Radiology 1999 Related to MV duration Importance unclear Most normal @ 1 year
  • Slide 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
  • Slide 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 1 Quinlan, Br J Anesthesia 1998
  • Slide 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
  • Slide 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
  • Slide 28
  • Neuropsychological effects of critical illness Cognitive impairmentPsychological impairment
  • Slide 29
  • Neuropsychological effects ICU environment Noisy Stressful & foreign Confusing, no day/night Painful & uncomfortable Sleepless Psychoactive drugs Sickness Traumatic!
  • Slide 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
  • Slide 31
  • Prevalence of neurocognitive effects 25% - 100% of ICU survivors! Greater in specific groups (i.e. ARDS) Hopkins et al, CHEST 2006
  • Slide 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
  • Slide 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
  • Slide 34
  • 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
  • Slide 35
  • 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
  • Slide 36
  • 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
  • Slide 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
  • Slide 38
  • Consequences of neurocognitive defects ADLs quality of life medical costs Inability to return to work ARDS: 32% - 51% not working 1-yr later 1,2 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
  • Slide 39
  • Quality of life after critical illness
  • Slide 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

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