Page 138 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

104 PART 1: An Overview of the Approach to and Organization of Critical Care

In this chapter, we will review the important recent advances in our
• Approximately one-third to one-half of survivors of critical illness understanding of outcomes after critical illness and focus on newer data
will develop long-term neurocognitive impairments. on functional and neuropsychological disability in patients and fam-
• Early mobility during critical illness is safe and feasible. ily caregivers and early models of rehabilitation and intervention after
critical illness. Most literature remains focused on long-term outcomes
• ICU multidisciplinary early mobility rehabilitation programs designed after acute lung injury, but emerging data on sequelae of chronic critical
for patients who had good premorbid functional status improve illness will be included here as it adds depth to our current understand-
functional outcome at ICU and hospital discharge. The role for these ing of the spectrum of post-ICU disability. Finally, the chapter will
programs in less functional patients at ICU admission is unclear as is conclude with a commentary about the future direction of outcomes
the lasting effect of this early rehabilitation intervention on longer- work and potential rehabilitation strategies for patients and families
term outcomes. after critical illness.
• ICU self-help manual has been shown to improve physical out-
comes after critical illness.
• ICU diaries have been shown to improve psychological outcomes LONG-TERM OUTCOME MEASURES
IN CRITICAL ILLNESS
in patients after critical illness.
• Neurocognitive rehabilitation has shown some early benefit on The nature of the ICU outcomes literature has progressed from physi-
outcome and requires further study. ologic measures, mostly comprised of cardiopulmonary function, to
• Family caregivers also experience psychological morbidity and are the study of generic health-related quality of life (HRQoL). These early
data suggested important decrements in physical function without a
important modifiers of patient outcome over time.
clear understanding of specific contributing factors. This was fol-
12
lowed by more recent data suggesting that physical HRQoL was heavily
influenced by ICU-acquired muscle wasting and weakness. Additional
13
findings have been added to these observations including prevalent
ABSTRACT neurocognitive disability and mood disorders. Contemporary out-
14
15
comes work focuses on functional independence to inform HRQoL
5
An episode of critical illness is transformative. Patients suffer important
new nerve, brain, and muscle injury that results in important func- outcomes and includes diverse patient samples comprised of different
clinical phenotypes with varied and distinct outcome patterns con-
tional limitations that affect health-related quality-of-life (HRQoL)
outcomes. The spectrum of morbidity varies according to individual tributing to a more comprehensive understanding of the spectrum of
disability after critical illness. The spectrum ranges from the young
risks but prevalent disabilities transcend diagnostic groupings. Each 2 4,5
patient who enters the intensive care unit (ICU) will begin to degrade and previously healthy, older with comorbid illness, elderly with
preexisting functional disability, and the very long-term ventilated
4
16
his or her muscles through upregulation of different proteolytic
pathways, and although the inciting stimulus, or its magnitude, may patient, and how these phenotypic groupings migrate with different
functional dependences, mood disorders, health care utilization and
differ somewhat across patients, the result is the same. This argues
for an approach to rehabilitation that is etiologically neutral and disposition.
Patients with acute lung injury and acute respiratory distress syndrome
based on an understanding of molecular pathophysiology that can
be mapped to functional outcome and tailored to individual need. (ALI/ARDS) have served as the archetype of complex critical illness and
its outcomes. ALI/ARDS is a clinical syndrome of rapid onset bilateral
Neuropsychological dysfunction is important and also potentially 17,18
irreversible and similar to that of moderate traumatic brain injury and pulmonary infiltrates and hypoxemia of noncardiac origin. In 2005,
it was estimated that ALI/ARDS affected 190,600 people per year in the
mild dementia. Cognitive interventions may need to follow a similar
rehabilitation model to those proposed for ICU-acquired weakness United States and was associated with 74,500 deaths, and 3.6 million
hospital days. In the United States, over 100,000 patients will survive
19
(ICUAW). Family caregivers should be part of the rehabilitation 19
intervention as they represent important risk modifiers of short- and ALI/ARDS each year ; they have been the most rigorously studied
group of ICU survivors to date and their outcomes will form the basis
longer-term outcomes.
of the discussion to follow. There is an important emerging literature
on longer-term outcomes in the chronically critically ill, the elderly, and
sepsis patient populations, and these data will be included where relevant.
KEYWORDS
HEALTH-RELATED QUALITY OF LIFE
cognition, critical illness, family caregiver, ICU-acquired weakness,
muscle biology, neuropsychological disability, outcomes, rehabilitation HRQoL is an important patient-centered outcome. However, it is
intensely personal and reflects personal values. As such, it may not
represent the best outcome measure to inform details of functional or
neuropsychological disability and how to construct individually tailored
BACKGROUND rehabilitation programs to meet specific needs.
HRQoL is defined as a set of causally linked dimensions of health,
Surviving critical illness is only the beginning. Only recently has it including biologic/physiologic, mental, physical, social function, neu-
become clear that an episode of critical illness results in long-term phys- rocognitive, and health perception. Measures of HRQoL assess how
20
ical and neuropsychological dysfunction, ongoing health care utilization disease and its treatment are related to physical, social, emotional,
and incurred costs, and the risk of financial and mental health devas- and neurocognitive functioning and it has emerged as an important
tation of families. This acquired disability may be irreversible. The patient-centered metric of recovery from critical illness. There is emerg-
1-9
2
legacy of muscle, nerve, and brain dysfunction may necessitate a change ing evidence that the degree of disability acquired after critical illness
in disposition where those who were previously living independently and resultant HRQoL may be variable and related to differences in
may require assisted living situations or comprehensive care after their premorbid functional status, burden of comorbid illness, and nature and
critical illness. Acquired morbidity comes at significant additional duration of critical illness. This heterogeneity is important to consider
4,5
cost with some reports that health care utilization after critical illness is when attempting to risk stratify patients for early mobility and post-ICU
similar to that for patients with chronic disease. 2,10,11 rehabilitation interventions.
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