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CHAPTER 15: Long-Term Outcomes After Critical Illness 103

TABLE 14-4 Surrogate Decision Maker and Physician Estimates of Prognosis • Cox CE, Martinu T, Sathy SJ, et al. Expectations and outcomes
for CCI Patients of prolonged mechanical ventilation. Crit Care Med. November
Surrogate Decision Makers Physicians 2009;37(11):2888-2894; quiz 2904.
• Hollander JM, Mechanick JI. Nutrition support and the
High expectations for:
chronic critical illness syndrome. Nutr Clin Pract. December
One-year survival 93% 43% 2006;21(6):587-604.
Physical function 71% 6% • Huang SS, Septimus E, Kleinman K, et al. Targeted versus univer-
Quality of life 83% 4% sal decolonization to prevent ICU infection. N Engl J Med. June 13
2013;368(24):2255-2265.
Responses of surrogate decision makers for CCI patients and their physicians to questions of expectations for
long-term survival, functional status, and quality of life. Overall surrogate-physician concordance in expecta- • Jubran A, Grant BJ, Duffner LA, et al. Effect of pressure support
tions was poor (κ <0.08), suggesting ineffective communication of expected outcomes by clinicians. vs unassisted breathing through a tracheostomy collar on weaning
Data from Cox CE, Martinu T, Sathy SJ, et al. Expectations and outcomes of prolonged mechanical venti- duration in patients requiring prolonged mechanical ventilation:
lation. Crit Care Med. November 2009;37(11):2888-2894. a randomized trial. JAMA. February 20, 2013;309(7):671-677.
• Kahn JM, Werner RM, David G, Ten Have TR, Benson NM,
Asch DA. Effectiveness of long-term acute care hospitalization
TABLE 14-5 ProVent Score for Mortality Prediction in CCI in elderly patients with chronic critical illness. Med Care. January
One-Year 2013;51(1):4-10.
Cumulative Mortality % • Nelson JE, Meier DE, Litke A, Natale DA, Siegel RE, Morrison RS.
Risk Factor a Points Point Score Patients % (95% CI) The symptom burden of chronic critical illness. Crit Care Med.
Age ≥65 years old 2 0 28 20 (10-29) July 2004;32(7):1527-1534.
Age 50-64 years old 1 1 23 36 (24-48) • Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physi-
cal and occupational therapy in mechanically ventilated, criti-
Vasopressors 1 2 30 56 (45-68)
cally ill patients: a randomised controlled trial. Lancet. May 30,
Platelet count ≤150 × 10 /L 1 3 14 81 (67-94) 2009;373(9678):1874-1882.
9
Renal replacement therapy 1 4-6 5 100 (77-100) • Unroe M, Kahn JM, Carson SS, et al. One-year trajectories of care
a Risk factors measured on day 21 of mechanical ventilation uninterrupted by more than 72 hours. and resource utilization for recipients of prolonged mechanical
Adapted with permission from Carson SS, Kahn JM, Hough CL, et al. A multicenter mortality prediction ventilation: a cohort study. Ann Intern Med. 2010;153(3):167-175.
model for patients receiving prolonged mechanical ventilation. Crit Care Med. April 2012;40(4):1171-1176. • Zilberberg MD, Shorr AF. Prolonged acute mechanical ventilation
and hospital bed utilization in 2020 in the United States: implica-
and surrogate decision makers in formulating goals of care for patients is tions for budgets, plant and personnel planning. BMC Health Serv
being studied in a multicenter randomized trial. 70 Res. 2008;8:242.

CONCLUSIONS

CCI is a rapidly growing problem for many ICU patients, their caregivers, REFERENCES
and the health care system. Management of the CCI patient must be
responsive to their unique physiologic state with an emphasis on restor- Complete references available online at www.mhprofessional.com/hall
ing strength and function while ventilator weaning progresses, and
avoiding new complications. CCI patients require significant health
care resources for prolonged periods, and long-term survival and func-
tion are poor for patients with irresolvable or recurring organ failure. CHAPTER Long-Term Outcomes After
Clinicians should engage patients and surrogate decision makers in
discussions of prognosis, patient values, and goals of care early in the 15 Critical Illness
course of CCI.
Margaret S. Herridge
Jill I. Cameron
Ramona O. Hopkins
KEY REFERENCES
• Boomer JS, To K, Chang KC, et al. Immunosuppression in patients KEY POINTS
who die of sepsis and multiple organ failure. JAMA. December 21,
2011;306(23):2594-2605. • Survivors of critical illness experience important functional dec-
• Carson SS, Kahn JM, Hough CL, et al. A multicenter mortality rements and decreased health-related quality of life due to ICU-
prediction model for patients receiving prolonged mechanical acquired weakness and a spectrum of other physical disabilities,
ventilation. Crit Care Med. April 2012;40(4):1171-1176. neurocognitive and neuropsychological dysfunction.
• Carson SS, Vu M, Danis M, et al. Development and validation of a • These morbidities may not be wholly reversible and the decrement
printed information brochure for families of chronically critically in function may be more marked in older patients, those with a
ill patients. Crit Care Med. January 2012;40(1):73-78. greater burden of comorbid illness or longer ICU length of stay.
• Cox CE, Carson SS, Lindquist JH, Olsen MK, Govert JA, Chelluri • Poor neurocognitive outcomes have been linked to delirium,
L. Differences in one-year health outcomes and resource utiliza- hypoxia and sedative-hypnotic use, hypoglycemia, and possibly
tion by definition of prolonged mechanical ventilation: a prospec- conservative fluid management; dysfunction is similar to that of
tive cohort study. Crit Care. 2007;11(1):R9. moderate traumatic brain injury and mild dementia.

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