Page 135 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 14: Chronic Critical Illness 101

CCI patients are prone to skin breakdown, particularly in the regions speech therapy, or occupational therapy can be provided more consis-
of the sacrum, coccyx, and heels. Pressure ulcers become an important tently. These dedicated units have taken a number of forms, including
site of infection, protein loss, and discomfort. Courses of antibiotics, separate units in acute care hospitals, specialized units in acute rehabil-
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débridements, and diverting colostomies that are required for treatment itation hospitals or subacute care facilities, or LTAC hospitals designed
of the ulcers further complicate a complex medical course. Frequent specifically for the care of CCI patients. Prolonged ventilator units vary
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turning of supine, bedbound patients is essential for prevention, but care in the type and acuity of the patients they manage. This variation is
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should be taken to avoid skin breakdown in other areas, such as the ears, usually driven by local resource needs, reimbursement restrictions, and
greater trochanter, and lateral malleoli. Specialty beds offer benefit and overall goals of care. Some units exist primarily to off-load the acute
should be considered as soon as a persistent immobilized state becomes ICU of patients with prolonged courses and poor prospects of recovery.
likely. Specialty beds should not, however, lead to relaxed vigilance Other units restrict admissions to patients who have good rehabilitation
toward skin condition in vulnerable sites. potential and can benefit most from a multidisciplinary approach to
■ PSYCHOLOGICAL SUPPORT weaning and comprehensive rehabilitation.
A recent large observational study compared long-term survival for
Common barriers to ventilator weaning and physical therapy include CCI patients who were transferred to LTAC hospitals to survival for simi-
lar patients who continued care in acute hospitals. Of 234,799 Medicare
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oversedation and delirium. Over 63% of patients with CCI experience patients with CCI, 20.6% were transferred to LTAC hospitals. Survival was
delirium or coma. Limiting sedative medication improves delirium, as not different for those who were transferred to LTAC hospitals after adjust-
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does maintaining day/night cycles; facilitating use of eye glasses and ing for patient and hospital characteristics as well as instrumental variables
hearing aids; and encouraging family visitation, mobilization, and other to account for selection bias (distance from nearest LTAC and number of
forms of patient engagement. Alert patients are better able to partici- LTACs in the region). ICU physicians should familiarize themselves with
pate in weaning efforts and physical therapy. Importantly, they are also the units and facilities that are available in their region. They should be
able to communicate their symptoms, which can allow the clinician aware of the resources that are available and general approaches to care in
to formulate a more rational approach to anxiolysis, pain control, and each facility so that they can make referrals according to patient needs and
diagnosis and management of depression. best possible outcome. Referrals to facilities outside the acute hospital set-
Symptoms of depression are common in CCI patients. 45,46 Depression ting should be made only when it is clear that complex diagnostic services
should be considered in patients who appear unmotivated despite are no longer required for the patient and that the receiving center can
gradual improvement in their condition or in those with persistent symp- manage any active medical or surgical issues adequately. It should also be
toms of delirium despite simplification of their medical regimen. This remembered that a marginally stable patient in an acute ICU setting may
should not be considered a “reactive depression” related to their difficult become somewhat unstable with the stress of transportation.
circumstances because there are usually other important contributors. Only a minority of CCI patients will have access to specialized acute
Many patients, particularly the elderly, have preexisting depression that hospital units or LTAC hospitals. The rest will continue to receive care
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was either being treated or undiagnosed. Changes in the neurohumoral in the acute ICU setting until they are free of life-sustaining therapies.
axis described earlier may play a role, and other metabolic disturbances This should not be an impediment to excellent care. Physicians and
could contribute as well. After correcting medical factors, including con- nurses should adapt their approach to care of the patient according to the
trol of pain and delirium, antidepressants can be started, especially when principles discussed earlier, and they should involve the essential ancil-
the depressive symptoms are interfering with the patient’s participation lary services as soon as indicated. For hospitals that do not have access to
in care. It should be remembered that clinical benefit from such medical specialized facilities, multidisciplinary care teams consisting of physicians,
therapies is slow to develop, so doses should not be escalated rapidly. Low respiratory therapists, nutritionists, physical therapists, and social workers
doses of psychostimulants such as methylphenidate can be considered who have expertise in managing chronic critical illness can be helpful. 53
when a more immediate impact is desired. Taking time to communicate
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with the patient, promoting family interactions, and general supportive
care can be very effective and will also have an immediate impact. OUTCOMES
anxiety, and sleep disturbance. These symptoms can elicit physiologic ■ SURVIVAL
Other common symptoms in CCI patients include dyspnea, pain,
3
responses that will worsen the course of critical illness, such as increased Despite the poor physical condition of most CCI patients, cohort studies
oxygen consumption, immune dysfunction, protein catabolism, and enrolling patients from acute care hospitals consistently indicate that 70%
electrolyte disturbance. Addressing these symptoms through appro- of patients are weaned from mechanical ventilation, and between 60% and
priate medical and environmental interventions may improve patient 80% survive hospitalization. 16,54-56 This is similar hospital survival to that
outcome while providing humane care for a desperately ill patient. of mechanically ventilated patients who do not develop CCI. However,
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Frustration from inability to communicate is a particularly common due to their ongoing medical problems and limited physical reserve, fewer
problem that exacerbates other symptoms. Letter boards and writing than 10% of patients are discharged to home. Instead, patients are sent
pads should be easily accessible to patients. One-way valves on tracheos- to LTAC hospitals, skilled nursing facilities, or inpatient rehabilitation
tomies that allow for air passage through the vocal cords with cuff defla- hospitals. Most of these facilities are designed to promote further recov-
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tion should be used as soon as the patient is able to protect the airway. ery and rehabilitation; however, almost all patients cycle between institu-
Regaining vocalization is a tremendous relief for the patient. Most of all, tions due to new complications and persistent functional limitations.
time should be taken to inform the patient of his or her condition and Patients experience a median of four transfers of care after acute hospital
elicit responses and concerns. Palliative care consultation can facilitate a discharge, and 74% of days alive during the subsequent year are spent in
personalized approach to symptom management. 45 institutionalized care or receiving professional care at home. Not surpris-
ingly, only 40% to 50% of CCI patients are alive after 1 year, and only 10%
■ ALTERNATIVE SITES OF CARE are functionally independent at home. 16,54,57,58 The poor long-term survival

In the 1980s, clinicians in the ICU began to understand the unique med- of CCI patients is a remarkably consistent outcome over 20 years.
could be better accommodated in settings removed from the acute ICU. ■ FUNCTION AND QUALITY OF LIFE
ical requirements of CCI patients, and recognized that these needs often
Managing stable CCI patients outside the ICU allows for lower nurse- CCI patients experience considerable functional limitations in long-
to-patient ratios, which can result in cost savings for the acute hospital. term follow-up. Compared to patients who require short-term mecha-
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At the same time, other essential services such as physical therapy, nical ventilation, CCI patients require assistance with an average of

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