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

those patients who were previously functional. 83,244-248 It is practical and
logical to trial physiotherapy and occupational therapy interventions in • Cuthbertson BH, Rattray J, Campbell MK, et al. The PRaCTICaL
study of nurse led, intensive care follow-up programmes for
those for whom there is a high likelihood for benefit. However, this
83
approach, while important and laudable, will not determine how inter- improving long term outcomes from critical illness: a pragmatic
randomised controlled trial. BMJ. 2009;339:b3723.
ventions should be tailored to meet individual needs nor differentially
applied since there are almost no guidelines on specific patient sub- • Herridge MS, Tansey CM, Matte A, et al. Functional disability
groups. For example, offering such interventions to subpopulations of 5 years after acute respiratory distress syndrome. N Engl J Med.
patients whose muscles and nerves have sustained such profound injury 2011;364(14):1293-1304.
that they have lost any potential for rehabilitation may raise expectations • Iwashyna TJ, Ely EW, Smith DM, Langa KM. Long-term cognitive
inappropriately. Investigations of the effects of physical rehabilitation on impairment and functional disability among survivors of severe
neuromuscular outcomes are few. A recent multicenter randomized trial sepsis. JAMA. 2010;304(16):1787-1794.
of 286 critically ill patients assessed HRQoL comparing outcomes from • Mikkelsen ME, Christie JD, Lanken PN, et al. The ARDS Cognitive
a nurse-led intensive follow-up program to standard care at 12 months. Outcomes Study (ACOS): long-term neuropsychological func-
There was no difference in HRQoL on the physical or mental health tion in acute lung injury survivors. Am J Respir Crit Care Med.
component scores; however, the nurse-led follow up program cost sig- 2012;185(12):1307-15.
nificantly more than standard care. Alternatively, a self-help manual
249
with instructions for physical therapy improved 6-month outcomes in • Myhren H, Ekeberg O, Toien K, Karlsson S, Stokland O. Posttraumatic
physical function assessed using the SF-36 HRQoL instrument and per- stress, anxiety and depression symptoms in patients during the first
haps patients and families will use this guide to tailor to individual need, year post intensive care unit discharge. Crit Care. 2010;14(1):R14.
although this was not studied explicitly in this trial. • Pandharipande PP, Girard TD, Jackson JC, et al. Long-term
There has been some early work evaluating potential interventions to cognitive impairment after critical illness. N Engl J Med.
improve neuropsychological disability. As noted above, Jones and col- 2013;369(14):1306-1316.
leagues evaluated whether a prospectively collected diary of a patient’s • Unroe M, Kahn JM, Carson SS, et al. One-year trajectories of care
ICU stay could reduce the development of new onset PTSD during and resource utilization for recipients of prolonged mechanical
convalescence after critical illness. Patients with an ICU stay of more ventilation: a cohort study. Ann Intern Med. 2010;153(3):167-175.
126
than 72 hours were recruited to the study and intervention patients • Wunsch H, Christiansen CF, Johansen MB, et al. Psychiatric
received their ICU diary at 1 month after ICU discharge and assessment
of the development of PTSD was made at 3 months. They were able to diagnoses and psychoactive medication use among nonsurgical
critically ill patients receiving mechanical ventilation. JAMA.
demonstrate that there was an associated decrease in the diary group of
new onset PTSD. These early data are very promising but further under- 2014;311(11):1133-1142.
standing of the longer-term effect of the diary intervention is warranted.

SUMMARY REFERENCES
The current state of the art in the ICU outcomes literature suggests that Complete references available online at www.mhprofessional.com/hall
patients will sustain some degree of neuromuscular, functional, and/or
neuropsychological morbidity as a result of their critical illness, which
does not appear to be wholly reversible over time, even in younger
patients who were previously working and highly functional. Family CHAPTER Care of the Caregiver in the
caregivers may acquire new mood disorders that impair their HRQoL
and may also modify outcomes in those patients surviving critical 16 ICU and After Critical Illness
illness. ICUAW represents a central morbidity and studies on interven-
tions such as early mobility and ICU multidisciplinary interventions are Yoanna Skrobik
promising but more work needs to be done on risk stratification so that
programs can be tailored to individual and family needs. Future work
needs to be directed to a more complete understanding of the patho- KEY POINTS
physiology of ICUAW and neuropsychological dysfunction to better
inform emerging rehabilitation interventions and the incorporation of • Fifty percent (50%) of physicians and nurse caregivers working
family caregiver needs into these programs. in intensive care units (ICUs) are reported to experience burn-
out. Physician burnout is attributable to the number of working
hours (number of night shifts, and vacation time and frequency),
whereas burnout among ICU nurses is mainly related to ICU orga-
nization and end-of-life care policy.
• ICU conflicts are independent predictors of burnout for both
KEY REFERENCES
physicians and nurses. Recent studies identify potentially effec-
• Barnato AE, Albert SM, Angus DC, Lave JR, Degenholtz HB. tive preventive measures. Despite identification of associations
Disability among elderly survivors of mechanical ventilation. Am and triggers, no prospective study addresses the issues of impact
J Respir Crit Care Med. 2011;183(8):1037-1042. on quality of care or caregiver outcome, or effective management
• Batt J, Dos Santos CC, Cameron JI, Herridge MS. Intensive-care strategies once burnout occurs.
unit acquired weakness (ICUAW): clinical phenotypes and molec- • Standardized communication strategies appear key to ensure safety,
ular mechanisms. Am J Respir Crit Care Med. 2013;187(3):238-246. effective functioning, and harmonious end-of-life decision making
• Choi J, Sherwood PR, Schulz R, et al. Patterns of depressive symp- and care; physicians may not be natural leaders in establishing inter-
toms in caregivers of mechanically ventilated critically ill adults professional intensive care communication strategies. Communication
from intensive care unit admission to 2 months postintensive care should be considered a safety feature on par with infection control,
unit discharge: a pilot study. Crit Care Med. 2012;40(5):1546-1553. and requires organization and buy-in from all stakeholders.

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