long term outcomes

Jozef Kesecioglu

Quality of life after ICU in different patient populations

Possible outcomes after critical illness

Basics for predicting outcomes

“Prediction is very difficult, especially if it's about the future”

Niels Bohr

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

4 phases of mortality

Niskanen 1996Flaatten, 2010

• 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

Crit Care Med 2008; 36:1523–1530

Outline

• Physical impairments after ICU

• Non-physical impairments after ICU

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


• 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

Specific physical problems

Herridge, NEJM 2011; 364:1293-304

• 109 survivors of ARDS

• multiple evaluations until 5-y follow-up

Herridge, NEJM 2011; 364:1293-304

SF-36 Mental (MCS) and Physical (PCS)



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


Herridge, NEJM 2011; 364:1293-304

6-minute walk test


Weight loss

Herridge, NEJM 2003;348:683-93


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


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

Outline

• Physical impairments after ICU

• Non-physical impairments after ICU

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

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

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.



• 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

Traumatic eventNo. 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%



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




• 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

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”


Cognitive decline following ICU

Systematic review

• 10 studies

• neuropsychological tests to measure cognitive function

• mean sample size 45 patients per study

"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"

Hopkins R O , Jackson J C Chest 2006;130:869-878

A possible explanatory model of neurocognitive impairments among ICU

survivors.

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

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)

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

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

JAMA 2010;304(16):1787-94

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

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)

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


TOPIC:

THE ART OF TRAUMA

RESUSCITATION


ESICM 28th Annual Congress

long term outcomes

Health & Medicine