ICU-acquired weakness and recovery from critical illness What doesn’t kill you makes you weaker Sandra Oeyen Intensieve Zorg UZ Gent “Surviving Intensive Care: a report from the 2002 Brussels Roundtable.” Angus et al. Intensive Care Med 2003; 29: 368-377  The traditional goal of intensive care has been to decrease short-term mortality. While worthy and extremely important, this goal fails to address the issue of what it means to survive intensive care. Key questions include  whether ICU survivors have optimal long-term outcomes  whether ICU care decisions would change if we knew more about these outcomes Co-morbidity = underlying health status: important for long-term outcome always obtain a thorough history!  co-morbidity LOOK AND THINK OUTSIDE THE BOX….  How will the patient survive the chronic phase?  patients and families measure success by return to pre-ICU facilities  independent living  return to work  no suffering HEALTH RELATED QUALITY OF LIFE HRQOL QOL persoonsgebonden voldoening of tevredenheid in de verschillende domeinen (fysiek – mentaal – sociaal) van het leven en hoe dit beïnvloed wordt door de gezondheid van een persoon How to measure quality of life?  Specific instruments   focus on aspects specific to conditions (disease, population, …) Generic instruments (which can be used for every patient)  Short-Form 36 (SF 36)     36 questions physical health: physical functioning - physical limitations - pain - general health mental health: vitality - social functioning - emotional limitations - mental health EuroQol-5D or EuroQol-6D (EQ-5D, EQ-6D)   5 domains : mobility; self-care; usual activities; pain; anxiety-depression 6 domains: + cognition Oeyen S et al. Quality of life after intensive care: A systematic review of the literature. Crit Care Med 2010; 38: 2380-400  worst long-term QOL:      severe ARDS prolonged mechanical ventilation severe trauma severe sepsis influence?       severity of illness comorbidity preadmission QOL age gender acquired complications Physical dysfunction is common Intensive care unit acquired weakness = ICU-AW  long-standing consequences have large effects on recovery ICU-AW = CIM and/or CIP  CIM= critical illness myopathy (primary myopathy) muscle fibre atrophy – muscle necrosis  CIP = critical illness polyneuropathy distal axonopathy ICU-acquired weakness: long-term consequences  muscle wasting and weakness  fatigue  pain – painful joints  poor appetite, dysphagia, cachexia, weight loss  voice and taste changes  skin and nail changes, hair loss  sexual dysfunction  pruritis Mental dysfunction is common  poor QOL physically (younger patients!)  fear of death - anxiety – depression  PTSD (>> benzodiazepines during ICU – NOT severity of illness!)  disturbed sleep - insomnia  lack of confidence  lack of libido  guilt - social isolation  previous psychiatric history  familial consequences – marital difficulties - financial difficulties Cognitive impairment is common  90% at hospital discharge    decreased to 25-78% within 1-2 years higher in ARDS clinically underappreciated!!  decreased QOL  inability to work  poor concentration – poor memory  associated with ICU delirium What can we better do to improve patient outcomes? PICS  Recognise and be aware of PICS    Family and GP may have little understanding of ICU and the problems patients faced Family members may also suffer from this critical care event (PICS-F) knowledge/ information: information brochure, videos, social media What can we better do to improve patient outcomes? PICS Critical Care Medicine 2014  examined in 11 studies – including 2 RCT  >> diary usage in Scandinavia (40-76% ICUs) and UK  Aim? to fill the memory gaps to promote psychological recovery Diaries for patients may, with further research, be shown to be very effective. However, the provision of diaries to ICU patients and its study are in their infancy, with more questions than answers. So….PICS….and now?!  Few proven specific therapies for PICS but…. the PICS concept is new and research just started recently  Often post-ICU patients do not have access to certain interventions because they do not qualify for these interventions as they have not a certain diagnosis; for example stroke, AMI, post CABG revalidation, respiratory revalidation,…  We can not change a lot of things in the post-ICU phase:       families co-morbidity rehabilitation social interplays quality and continuum of care from ICU – home environment How much of the morbidity we see in ICU survivors is actually caused by the acute illness? ABCDE + FGH already during ICU admission : PREVENT PICS!! ABCDE + FGH to prevent PICS       ABC: Awakening and Breathing Coordination (agitation and sedation): reduce use of sedatives - allow patients to be more alert D: delirium assessment/monitoring E: early exercise, early mobilisation (starts in the ICU!) F: family inclusion, follow up referrals G: good hand-off communication, family communication H: hand family written information, diary Critical Care Medicine 2014  prospective cohort before-after study  624-bed tertiary center  5 adult ICUs, 1 step-down unit, 1 onco-hemato special care unit  prebundle: feb-oct 2011; 146 pts  SAT and SBT conform individual ICU physican’s practice (safety? success? failure?)  no delirium or management policies in place  patients were not routinely assisted out of bed  postbundle: oct 2011- april 2012; 150 pts  ABCDE bundle applied to every patient (regardless ventilation) unless order NOT to apply the bundle (opt-out method) Pre-ABCDE bundle Post-ABCDE bundle Unadjusted P Ventilator free days; median (IQR) 21 (0-25) 24 (7-26) 0.04 Delirium anytime, N (%) 91 (62.3) 73 (48.7) 0.02 % ICU days spent delirious; median (IQR) 50 (30-64.3) 33.3 (18.8-50) 0.003 Out of bed mobilization, N (%) 70 (48) 99 (66) Hospital mortality, N (%) 29 (19.9) ICU mortality, N (%) ICU-LOS (days); median (IQR) Hospital LOS; median (IQR) Adjusted odds ratio Adjusted P 0.55 (0.33-0.93) 0.03 0.002 2.11 (1.30-3.45) 0.003 17 (11.3) 0.04 0.56 (0.28-1.10) 0.09 24 (16.4) 14 (9.3) 0.07 5 (3-8) 4 (3-5) 0.21 13 (9-15) 11 (9-13) 0.99 Potential barriers to implementation of early rehabilitation in the ICU  gaps in knowledge of benefits of early mobilisation     improvement of muscle strength improvement of functionality improvement of QOL reduced costs due to reduced ICU- and hospital LOS  deep sedation  limited ICU staffing…