Page 144 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

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

Heterotopic ossification Tracheal stenosis PHASE-SPECIFIC APPROACH TO RECOVERY
Frozen joints AFTER CRITICAL ILLNESS
contractures Cosmesis—scars from CVC, art line, CT, drain sites ■
Nerve and muscle Brain TIMING IT RIGHT FRAMEWORK 104
Striae Alopecia The need for longer-term follow-up and ongoing support in the com-
munity are priorities for ICU survivors and their family caregivers.
Bronchiectasis Thus, when constructing rehabilitation interventions, their needs
Pulmonary must be considered across the full care continuum. In response to this
fibrosis Weakness Mental health & cognition Ischemic digits need, Cameron and colleagues developed the timing it right (TIR)
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framework to promote an organized approach for the development
and evaluation of interventions designed to meet patients’ and family
Renal impairment Taste changes caregivers’ changing needs. It was developed using the clinical course
Caregiver Hearing loss of stroke as a model of acute illness requiring ongoing recovery and
rehabilitation. This framework has been adapted to the ICU population.
FIGURE 15-6. Interaction of myriad physical and caregiver outcomes on the major mor- The five phases examine experiences and support needs during (1) the
bidities of critical illness. (ICUAW and Mental Health and Cognitive Dysfunction) critical illness event and ICU care, (2) period of stabilization on the
general ward, (3) preparation for return to community living, (4) first
few months of home adjustment, and (5) longer-term adjustment to
community living. The premise of this framework is that careful atten-
fundamentally from the International Classification of Disease (ICD), tion to phase-specific needs will enhance patient and family caregiver
which focuses on disease as a cause of death. The ICF (Fig. 15-6) has preparedness and ease their transitions across care environments. This
three constituent parts, body function and structures, activity, and par- longitudinal approach and the recognition that needs vary across tran-
ticipation, and offers a comprehensive and multidimensional approach sitions and over time will need to be incorporated into comprehensive
for rehabilitation interventions. This framework serves to highlight the rehabilitation strategies.
interdependence of factors that should be highlighted and integrated
into long-term and multimodality rehabilitation program. CRITICAL ILLNESS–ASSOCIATED BRAIN INJURY
The body functions and structures component of the ICF refers to
ment is characterized as any deviation from normal. Activity refers to ■ PSYCHIATRIC MORBIDITY
physical function and/or specific organ system injury where impair-
the ability to execute important activities and participation refers to Psychiatric sequelae following critical illness and ICU treatment
ability to conduct daily activity and “participation restriction” denotes are increasingly recognized. The prevalence and severity of psy-
difficulties experienced by patients when trying to carry out daily tasks. chiatric disorders including depression, anxiety, and posttraumatic
The constituent parts of the ICF capture function and disability and stress disorder are common among survivors of critical illness. The
interact with the health condition, as well as personal and environmental prevalence of depression and anxiety in ICU survivors ranges from
factors. This is an important departure from constructs of quality of life 10% to 58%. 1,28,105,106 In a recent systematic summary, Davydow and
that are personalized and capture a global functioning perspective based colleagues reported that 28% of post-ICU patients had clinically sig-
107
in feelings or satisfaction. For example, the generic short form-36 evalu- nificant depression. Neither sex, age nor severity of illness at ICU
ates functioning in a disease context and does not incorporate aspects admission were consistent risk factors for post-ICU depression. Early
of patient participation or personal factors or environmental influence post-ICU depressive symptoms were a strong risk factor for subsequent
on outcome. depressive symptoms and post-ICU depressive symptoms were associ-
ated with substantially lower HRQoL. While the range of depression
BARRIERS TO CONSTRUCTION OF REHABILITATIVE in survivors of ARDS is 17%-58%, there is a suggestion that ARDS
MODELS AFTER CRITICAL ILLNESS patients suffer a greater degree of depression compared to populations
The rates of depression in criti-
of general critically ill patients.
■ TRANSLATIONAL RESEARCH IN REHABILITATION cally ill patients are similar to the 22% to 33% observed in chronically
12,15,20,108
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AFTER CRITICAL ILLNESS 103 ill medical inpatients and 25% to 28% in patients with cardiac and
pulmonary disorders.
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The breadth and variability of morbidity after critical illness will elude Prospective evaluation of risk factors associated with depression in
us if we continue to study diseases or syndromes in isolation. We need ARDS patients showed relationships with longer duration of mechani-
to evaluate the spectrum of disability to determine robust themes and cal ventilation, ICU length of stay, and sedation. No study has been able
similarities across different disease states and gain an understanding to demonstrate a significant association between HRQoL and reported
of risk stratification and modification. There is increasing emphasis psychiatric symptoms in these patients. A recent study that assessed
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on the importance of basic science research and its role in elucidat- risk factors for depression and anxiety in ARDS survivors found predic-
ing the molecular aspects of muscle, nerve, and brain injury, which tors of depression at 1 year were alcohol dependence, female gender, and
constitute the major morbidities after critical illness. These insights younger age. The predictors of anxiety at 1 year were ratio of arterial
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will be crucial to optimize future rehabilitation programs since cur- oxygen tension to inspired oxygen fraction and duration of mechanical
rently there is inadequate information linking molecular mechanism ventilation. Predictors of depression at 2 years were depression and neu-
to functional outcome across patient groupings. However, it is crucial rocognitive sequelae at 1 year, whereas predictors of anxiety at 2 years
to also remain cognizant of the interplay of factors that contribute to was anxiety at 1 year. A recent study found that hypoglycemia may be
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better or worse outcomes both early and late in the illness. Research an important risk factor for depression in ARDS survivors and this war-
on treatments intended to address the impairments domain of the ICF rants further study. The observed depression and anxiety post-ICU
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(body structure/function) faces the challenge of determining the likely treatment are likely multifactorial and further study will be needed to
impact of an impairment-level treatment on the multifaceted activities, better understand patient predisposition, illness, and treatment-specific
and aspects of participation that are the typical outcomes of rehabilita- determinants of affective morbidity and appropriate tools for diagnosis
tion treatments. and monitoring.

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