long-term effects of critical illness khalid f. almoosa, md pulmonary, critical care, & sleep...

Long-term effects of critical illness

Khalid F. Almoosa, MD

Pulmonary, Critical Care, & Sleep Medicine

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 patient’s quality of life?

• What about the chronically critically ill?

?? ??

Today’s ICU

• 55,000 - 90,000 admissions/day1

• 80% of population will require ICU care during lifetime

1Schmitz et al, 1998

Today’s 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 ventilation2

1Halpern et al, Crit Care Med 19942Esteban et al, AJRCCM 2000

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

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

Factors affecting recovery from critical illness

Recovery

Family Psychological

Social

Physical

Employment

Pre-morbid state

Broomhead & Brett, Critical Care 2002

Components of Long-Term Outcomes

Physical Neurocognitive and psychosocial Quality of life Chronic critical illness

Life expectancy after critical illness

5-year mortality of ARF survivors

Garland et al, CHEST 2004

1000 patients3X morality

6 – 25% of ICU survivors – die before hospital d/c

Age Quality of Life

Determinants of Post-ICU mortality

Rivera-Fernandez et al, Crit Care Med 2006

(COPD)

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 20031385 patients

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

Physical effects of critical illness

• Nutrition

• Neuropathy

• Respiratory

• Cardiac

• Sexual

• Other


• Nutrition

• Neuropathy

• Respiratory

• Cardiac

• Sexual

• Other

• Cachexia– 2% loss of muscle mass

per day

– 50% during stay

Herridge et al, NEJM 2003


• Nutrition

• Neuropathy

• Respiratory

• Cardiac

• Sexual

• Other

appetite – weakness, altered taste, depression, dyspnea

• Mechanical difficulties


• 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


• Nutrition

• Neuropathy

• Respiratory

• Cardiac

• Sexual

• Other

• Dyspnea = common!– Muscle weakness,

neuropathy, fibrosis, progression of pre-morbid conditions, psychological

1Davidson et al, AJRCCM 1999

Pulmonary Function

• Most ARDS survivors – abnormal PFT @ discharge but achieve normal spirometry & volumes @ 6 – 12 months1-3

• Some restrictive defect, DLCO– Significance unclear

• ?exercise tolerance

1McHugh et al, AJRCCM 19942Heyland et al, Crit Care Med 20053Herridge et al, NEJM 2003

Herridge et al, NEJM 2003


• Nutrition

• Neuropathy

• Respiratory

• Cardiac

• Sexual

• Other

• Persistent CXR changes– CT: Coarse reticular

pattern, ground glass

Long-term radiographs changes

Desai et al, Radiology 1999

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


• Nutrition

• Neuropathy

• Respiratory

• Cardiac

• Sexual

• Other

• ? Postural hypotension

• No documented adverse effects of ICU on cardiac function

• Sparse data


• 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


• 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

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 2002Griffiths & Jones, BMJ 1999

Neuropsychological effects of critical illness

Cognitive impairment Psychological impairment

Neuropsychological effects

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

Traumatic!

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

Prevalence of neurocognitive effects

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

Hopkins et al, CHEST 2006

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


• 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



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



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



problems

* Hopkins et al, Crit Care Med 1999

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



problems

• Family members – develop anxiety, depression

• Post-D/C = overprotective, unrealistic expectations = frustration

• Quit work or major life changes

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 support1Hopkins et al, AJRCCM 20052Herridge et al, NEJM 2003

Quality of life after critical illness

(HR) Quality of life

• Multi-dimensional concept– Subjective & objective– Difficult to study

• Encompass all areas of patient’s life– Physical, emotional, social, financial, – Preferences, values, perception, altitude– Differ among age, cultures

• Current status/knowledge in QoL in ICU patients poor

Quality of Life

Orwelius et a, Crit Care Med 2005

2-center562 patients6-month f/uMailed survey

Quality of Life Influential factors

• Niskanen et al (CCM 1999)– 368 patients, single

center– > 4 days in ICU– Compare to random

sample of general pop.– Nottingham Health

Profile

Lower score = better

Diagnosis affects QoL

Quality of LifeChanges with time

Hopkins et al, AJRCCM 1999

55 ARDS pts

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?”

Quality of Life Effects of Pulmonary Function

Schelling et al, Int Care Med 2000

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

Quality of LifeCaregivers

Time of MV 13.9 days

Home

Rehab/NH/LTAC

49.6%

39.2%

Required CG 74.8%

Age of CG 52.9 years

(76.5% women)

CG % working 28.7%

CG work time/stop 30.3%

% spend > 4 hr/day > 50%

Depression 33.9%

115 patients’ CaregiversProlonged MV > 48 hrs

Im et al, CHEST 2004

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

How to improve quality of life

• Mobility

• Pain & sedation control

• Sleep management

• Discharge planning


• Mobility




- Muscle wasting & weakness- Early- Mechanical ventilation


• Mobility




- Psychological effects


• Mobility




- Common sleep disturbances- Modify environment


• Mobility



• Discharge planning - Not done in critical care- ICU transfer sheet- Transfer anxiety- “Weaning” nursing- Liaison nurse- Preparing for home- Communication w/ PCP

Chronic Critical Illness

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

Chronic Critical IllnessSurvival from MV patients from LTAC

Carson et al, Crit Care Clinics 2002

Chronic Critical IllnessQuality of Life

• Functional status & QoL after discharge– Better than expected

• NH placement, limitations

– Most do not survive– Limited data

Chatilla et al, Crit Care Med 2001

46 patients45 days on vent2 year f/u

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

“…For the secret of the care of the patient is in caring for the patient ”

- Dr. Francis W. Peabody

long-term effects of critical illness khalid f. almoosa, md pulmonary, critical care, & sleep...

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