CCP Podcast 052: Chronic Critical Illness

Desarmenien. The chronic critical illness: a new disease in intensive care. Swiss Med Wkly 2016;146:w14336

This paper is one from the Swiss Medical Weekly 2016 and is a description of the efforts to develop what they call a multi modal care management approach to those patients at risk of chronic critical illness. They call these patients PLS from the french term 'Patient Long Sejour'. In 2006 there was a realisation that this kind of patient needs to be managed differently from those in the acute phase and the formation of an interdisciplinary team helped in the development of a new approach. They defined the chronically critically ill (CCI) as those with a length of stay in the ICU of greater than seven days with a second criterion being the necessity for support by sophisticated means available only in the ICU. This group of patients;

• accounts for 12-18% of the 2500 patients admitted each year.
• Stay as long as 13.8 days.
• consume up to 52% of ICU resources.
• had a mortality of 15% (compared with 8-12% of general ICU population).

Their problems are many but some of the ones worthy of note are;

• Neuromuscular weakness
• ICU paresis
• Swallowing problems
• Muscle loss and increased adipose tissue
• Anxiety
• Depression
• Difficulty with communication.

Caregivers need to be able to have great skill in human relationships. There may be much conflict for these patients amongst them and their family or their carers or even their family and their carers. These conflicts are associated with burnout of their carers. An attempt to pool this kind of patient between 2006 and 2009 resulted in exhaustion of the team members. It failed for several reasons;

• burden of care
• difficult relationships with family members
• uncertain progress
• slow evolution of PLS.

One of the learning points from this attempt was that a specialist nurse should be used in the future to help be a resource for this type of patient and their family and to assist in training the carers in looking after this type of patient. They did identify some specific actions to be taken to ensure that the PLS patient is identified and helped as early as possible;

• After seven days the patient is highlighted with a PLS sticker and algorithm of care on the patient monitor
• Early mobilisation is encouraged. Muscle tone is assessed regularly by the physios.
  • Muscle mass diminishes by 2-% per day during critical illness
  • A weekly consultation with a specialist in rehabilitation to help the physios select the appropriate therapies.
• Under or over feeding of critical patients is associated with an increase in complications, costs and mortality. A dietitian is needed to ensure that this is monitored properly.
• They may also have swallowing problems which create a threat of inhalational pneumonia, so small calibre feeding tubes and access to a speech therapist are important.
• Neurocognitive assessment using modified mini mental state examination is helpful to anticipate, detect and monitor potential neurocognitive disorders.
• Visual calendar to help decrease patient disorientation.
• Diaries- patients will often have delusional memories, nightmares and/or hallucinations. Diaries can help reconstruct the patients ITU experience and has been shown to prevent PTSD.
• Multidisciplinary conferences whose purpose is to redefine the short medium and long-term therapeutic goals.
• Patients can experience a real loss when they are moved out of the intensive care unit and preparation is thus essential. the team organises an interview with the next caregiver team

After implementing these changes re admissions have decreased between 2014-2015. They are presently training carers in the use of massage to decrease the anxiety and pain of the patients as well as their sleep quality and sleep is the subject of their next research project.

Marchioni. Chronic critical illness: the price of survival. Eur J Clin Invest 2015;epublished November 9th

This paper addresses some of the pathophysiological aspects related to the development of Chronic Critical Illness. It first acknowledges that an absolute definition of CCI is not available but speculates that prolonged mechanical ventilation might be one of the factors. Prolonged in this instance is quoted as being 21 days of ventilation for a minimum of 6 hours per day. This population is growing with some studies reporting up 5-10% of patients admitted to ICU requiring prolonged mechanical ventilation. Only 10% of CCI patients achieve functional autonomy and live in their own home at 1 year after the onset of the acute condition requiring admission to ICU. Whilst respiratory failure is the main feature of CCI there are other features which are often present which include:

• Myopathy
• Neuropathy
• Loss of lean body mass
• Delirium
• Nutritional deficiency
• Immobility

There are no biomarkers that can assist in predicting the development of CCI but risk factors include old age, comorbidities, sepsis and ARDS. CCI is associated with persistent systemic inflammation and those patients presenting with higher inflammation levels at disease onset show worse progress and higher incidence of multiple organ failure. Those older patients have a chronic increase of some of the inflammatory markers putting them more at risk as a consequence. There is some impairment of the regulation of the processes aimed at limiting damage associated with inflammation which might be involved in the progression from the acute to the chronic phase and even a low inflammatory state may play a role. Endocrine abnormalities play a large part in the development of the acutely critically ill patient but have not been recognised for the chronically critically ill patient. Some of these processes are complex and perhaps merit more study in depth but to summarise the patients cortisol levels are very important in their attempts to fight disease. Cortisol causes a positive haemodynamic effect through intravascular fluid retention and increase in inotropic and vasopressor response to catecholamines and angiotensin II. It also has an anti-inflammatory effect. During sepsis, due to relative adrenal insufficiency, cortisol production is insufficient to maintain haemodynamic stability. Another endocrine impairment is hyperglyceamia secondary to the response to acute stress. Once hyperglyceamia is present, it may even persist. Some of the problems are best summed up by this quote from the paper:

The chronic process of a critical illness involves significant changes in neuroendocrine response. Evolution has not provided our nervous and endocrine system with the ability to withstand a prolonged inflammation requiring artificial life support.

 

Macintyre. Chronic critical illness: the growing challenge to health care. Respir Care 2012;57(6):1021-7

Like many other papers on this subject it starts with an attempt to pin down a definition. The main part of the definition it works with is the presence of prolonged mechanical ventilation discussing the length of this PMV as being 21 days of mechanical ventilation whilst also acknowledging that it could be as little as 14 or as much as 28 days ventilation. There is also the need to ensure that this population requires a different mindset to the acutely ill patient in ITU. Unlike the acutely ill patient the CCI patient is characterised by:

• slow fluctuations in function and care needs
• slow changing baseline which can be frequently interrupted by acute events

Caregivers with unique skills are needed and because outcomes are poor a culture of care that has a heavy palliative care influence is critical. In general yearly mortality is 40-50%. ProVent score:

• calculated at 21 days of mechanical ventilation
• age > 50yrs
• Platelets <150
• Need for vasopressors
• need for dialysis

If none of these factors present then survival was over 80%. However if all 4 were present there was virtually 100% mortality at one year. CCI is a persistent ongoing inflammatory state following an initial inflammatory insult. There is persistent elevations of cytokines and a failure of anti inflammatory processes to modulate and repair. Organ dysfunction may have left the patient with:

• heart failure
• liver failure
• adrenal failure
• neuromyopathies
• impaired cognition
• hormonal dysregulation and renal failure.

These can be combined with inappropriate clinician responses such as:

• inadequate antibiotics
• inappropriate ventilator settings
• fluid overload
• electrolyte mismanagement
• malnutrition
• excessive sedation
• nosocomial infection risks

Discussion then moves onto the venues of care with proponents of the long-term acute care hospital (LTAC) arguing that the culture of care is more rehab oriented with an emphasis on physical therapy, occupational therapy and respiratory therapy that is better suited to the patients long term needs. Issues of mechanical ventilation are covered. The injured lung has abnormal mechanics, abnormal dead space and impaired gas exchange that can overload the neuromuscular capabilities of the patient with CCI. Ventilator settings should be lung protective and there is no clear consensus on how best to remove/reduce ventilator support in this population. Spontaneous breathing trails should not be attempted until the support has been reduced to an appropriate level e.g. pressure support 10-15 cm, PEEP <5 and oxygen 0.5 or below. In those patients with a tracheostomy care should be taken when decannulating the patient with secretion issues or obstructive apnoeas. It is important to acknowledge that some patients will never be weaned off the ventilator- the literature indicates that 90% or more of those patients who eventually are weaned have the weaning complete by 90 days of mechanical ventilation. Supportive evidence for NIV in CCI is lacking. Nutritional support is important as many of the features of the CCI patient involve persistent catabolism, malnutrition and neuro-endocrine imbalance. Hypoglyceamia is a common problem as is bone resorption, vitamin B deficiency and anasarca. Bone dysfunction requires multiple strategies, including calcium replacement, vitamin D replacement and biphosphonates. They are at increased risk of infections because of multiple invasive devices, malnutrition, hyperglyceamia and immune exhaustion. Device associated infections can be limited by using appropriate care bundles. VAP would include head of bed elevation, minimised sedation, oral care, subglottic suctioning,peptic ulcer disease prophylaxis and DVT prophylaxis. Infection care bundles would include hand hygiene, complete barriers for central line insertion, chlorhexedine use, proper site selection and daily assessment for continued need of catheter. Neuromyopathies commonly occur in the critically ill being both myopathys (direct muscle injury) and polyneuropathy (diffuse axonal injury) both secondary to impaired oxygen delivery/uptake. Prevention and management of this would include good glucose control, reduction of neuromuscular blockers and steroids, optimisation of electrolytes and early mobilisation. Delirium should be managed taking care of the risk factors such as inflammation, hypotension, electrolyte shifts. sleep deprivation, hypoxeamia and drugs. There should be a more palliative care mindset which focuses on symptom relief , align treatment of patient and family wishes and provision of patient and family support.

Maguire. Strategies to combat chronic critical illness. Curr Opin Crit Care 2013;19(5):480-7

This starts by attempting to define what is meant by CCI. Initially they say it is those who have survived acute critical illness or injury, but have a persistent organ dysfunction leading to prolonged intensive care needs. Many of the definitions include the need for prolonged mechanical ventilation (PMV) but the length of that seems to vary greatly from 96 hours to 21 days. CCI is a syndrome which also includes profound weakness, malnutrition, anasarca (generalised oedema), prolonged brain dysfunction and extreme symptom burden. They feel that the presence of a tracheostomy might also make the patient inclusive in the CCI category, but they do conclude by saying that recognition is perhaps more important than any rigid definition. Depending on the definition, of the mechanically ventilated patients in the ICU 5-10% develop CCI and this number is projected to double in the next ten years. Based upon some cohort studies one-year survival for CCI is between 40-50%. The article then moves on to prevention and management of CCI and starts this by looking at mechanical ventilation. ARDS is most associated with CCI and some of the strategies concerned with this problem are highlighted. These include protective lung ventilation, conservative fluid management, sepsis bundles, daily awakening trials and spontaneous breathing trials. With the spontaneous breathing trial (SBT) they go on to compare tracheostomy collar groups with the pressure support based weaning protocol. In a trial of patients those with the tracheostomy collar weaned in 15 days compared to 19 days with pressure support. They go on to say that the optimal approach to weaning is not necessarily clear but there should be a more aggressive search for the causes of failure. ICU acquired weakness (ICUAW) is acknowledged as a well-recognised complication of critical illness. Perhaps one of the most interesting points in the paper and certainly one that should always be borne in mind is this;

In one study of patients requiring at least 28 days ventilation, neurophysiologic evidence of chronic partial denervation of muscle consistent with previous critical illness polyneuropathy can be found up to 5 years after ICU discharge in more than 90% of patients.

The risk factors which contribute to ICUAW include prolonged immobility, hyperglycaemia, systemic infection and multiple organ dysfunction. Possibly mitochondrial dysfunction, contributing to diaphragmatic weakness adds to the ICUAW and the role of systemic corticosteroids is unclear. One of the main recommendations under this heading is the early mobilisation of the patients being key to improving their outcomes. Malnutrition is reported in 43% of ICU patients and this is associated with increased morbidity, mortality, infection rates, ICU length of stay, poor wound healing and muscle weakness. Data still supports the use of enteral feeding in those patients with a functioning GI tract. Mean physical function and survival at 12 months in the ARDS patient were not affected by initial trophic versus full feed. The data is not conclusive when looking at adding parenteral to enteral feed but there is an observation that over feeding rather than underfeeding may be more common and this can lead to increased infectious complications, liver dysfunction and increased mortality. Cognitive impairment is a feature of this type of patient and affects a large number of them one year after ICU and there is possibly some relationship between acute delirium and long-term impairment. The most important way to manage this is to evaluate for any modifiable cause such as infection, hypotension, electrolyte imbalance, hypoxia and the use of sedatives. The ICU patients have a lot of invasive lines and some of the infections these produce may add to their potential to become a chronically critically ill patient. They speculate that 'immune exhaustion' is another mechanism that puts the patient at risk. So there should be basic infection control measures, a minimization of catheters and possibly decontamination using intranasal mupicirin and chlorhexedine cloths to reduce the incidence of MRSA. It is also noted that the patient and family wishes should also play a major part in the care of the critically ill. There should be frequent discussions about this covering areas such as thresholds for continuation or discontinuation of therapies, open and honest communication about eventual location of discharge and preparedness planning for upcoming therapies. The venue of care is also something which needs to be considered. Is it appropriate for this type of patient to be cared for in the acute ICU. We need to consider other centres which will particularly address their special needs. In summary, there needs to be prevention measures including:

• EGDT
• Lung protective ventilation
• Daily awakening
• Spontaneous breathing trials
• Early mobilisation
• Prevention of infections

and then management strategies of the CCI which will include:

• Ventilator strategies
• Nutrition strategies
• Rehabilitation strategies.

Interview Questions for Advanced Critical Care Practitioners

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