• Aucun résultat trouvé

After ICU.

N/A
N/A
Protected

Academic year: 2022

Partager "After ICU."

Copied!
12
0
0

Texte intégral

(1)

Article

Reference

After ICU.

MERLANI, Paolo, CONTI, Marco, RICOU, Bara

Abstract

There are numerous unrecognized or underestimated problems after ICU regarding physical and psychological recovery, as well as the family, social, employment and housing aspects. At the present state of knowledge, two main axes seem to prevail that would allow improving life after ICU: attempts to increase the physical strength and to increase the neuropsychological recovery. Further studies are needed to extend our knowledge about such outcomes and plan future strategies for improvement.

MERLANI, Paolo, CONTI, Marco, RICOU, Bara. After ICU. ICU Management , 2011, vol. 3, p.

6-8

Available at:

http://archive-ouverte.unige.ch/unige:25687

Disclaimer: layout of this document may differ from the published version.

1 / 1

(2)

After ICU

Paolo Merlani, MD, Marco Conti, MD, Bara Ricou, MD

Service of Intensive Care, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.

Address for correspondence

Ba Ricou

Intensive Care, Department APSI Geneva University Hospitals Rue Gabrielle-Perret-Gentil 4 1211 Geneva 14, Switzerland Tel: +41 22 382 74 73 Fa +41 22 382 74 70 E-mail: bara.ricou@hcuge.ch

ra

x:

Total : 2013 words

(3)

Introduction

Int ne is quite a recent medical discipline born around 1950. At its

beginning, the illusion of the medical world was that the new highly sophisticated techniques will allow the recovery of every single patient. A half century later, the discipline has grown up

mo les un

hospital budgets. ICU cost are growing and represents between 0.5 to 1% of the gross dom

su be mo quali

Rubenfeld et al., 1999). Among all critically ill patients, elderly or chronic critically ill patien

The aim of the present article is to describe some of the major difficulties encountered by the pa

an

co ovement in

their management and the targets start to be known.

ensive care medici

and we now realize that obviously many more lives can be saved, less patients die, but st of all, many patients survive with variable degrees of disability, some acceptable, some s acceptable and certainly not foreseen up to recently (Figure 1). Besides, intensive care its (ICU) are scarce resources that represent a large part of national health expenditure and

estic product (Halpern and Pastores, 2010, Jacobs and Noseworthy, 1990). These facts ggest that the aim of the intensive medicine should be directed towards outcomes that could considered more satisfactory on the patient's and society perspective. More than ICU

rtality, patient-centred outcomes such as long-term survival, the functional status or the ty of life (QOL) should be considered and advised to be sought (Angus and Carlet, 2003,

ts are especially prone to develop unsatisfactory outcomes.

tients after their stay in ICUs. Many of these difficulties are under reported, since patients d their relatives are so grateful towards the ICU caregivers that they would not dare to mplain. However, the literature shows now evidence that there is room for impr

(4)

Outcome after ICU: general considerations

M or follow up mortality{Williams,

2005 #630}. The multiple studies are difficult to compare, because the definition of ICU or hospital mortality depend on the organization or structure of the hospital and can differ among typ

IC the 8 t

up mortalities at 12 months after ICU ranging from 26 to 63%{Williams, 2005 #630}.

General It ass are mat

factors associated with 1 year mortality are older age, the presence of co-morbidities, the pre

nu IC dis and the mortality.

The morbidity after ICU can be divided 3 main fields: physical, non physical and others. The physical impairment can be addressed through specific organ dysfunctions or by a general ass

ortality can be described by different ways: ICU, hospital

es of ICU, of hospitals and countries (University versus non university, pediatric or adult U, general ICU versus specific ICU, presence of intermediate care or not), the case-mix and timing of the mortality assessment. Review articles describe ICU mortalities ranging from o 33%, hospital mortalities from 11 to 64%, 1 month mortalities from 15-21% and follow-

ly the most common mortality data used are the hospital or the 28/30 days mortality.

is only recently that ICU managers focus their attention on long-mortality. Mortality can be essed interestingly at 4 different moments (Figure 2). After discharge of the hospital, there still further deaths (the after-hospital excess mortality). Compared to an age- and gender-

ched population, the higher mortality persist up to 15 years after ICU discharge. The

sence of a new malignancy, some admission diagnosis, ICU admission severity and the mber of organ failures during the ICU stay. Additional factors, i.e. the male gender and the U length of stay are associated with an increased mortality up to 15 years after ICU

charge {Williams, #631; Williams, 2008 #632}. Emergency admissions, functional status Quality of Life (QOL) before ICU admission may also impact on after-hospital

essment of the status using validated instruments like the Activity of Daily Living or the Karnofsky index{Hayes, 2000 #141}. Studies indicate that the functional status is already

(5)

lower before ICU admission compared to an age- and gender-matched population{Dowdy, 20

similar to or only slightly reduced than before ICU in 2 thirds of patients. A great majority of patients will not need any help after ICU discharge. However there may be huge differences be

20 ins to

24 months, with chronic dyspnea or sequelae from tracheotomies{Herridge, 2003 #38}.

Polyneuropatias, weight loss and sexual dysfunctions may affect critically ill patients for ye

Co IC

3/4 nal

memories, panic attacks or insomnia{Granja, 2005 #36}{Flaatten, 2007 #633} Post-traumatic dis

the ma ris before

population{Dowdy, 2005 #154}. After ICU, most patients regain their pre-ICU QOL in 6-12 mo

mo yo

05 #154; Hennessy, 2005 #148; Kvale, 2002 #634}. After ICU, the functional status is

tween patients, depending on the ICU admission diagnosis{Dowdy, 2005 #154; Hennessy, 05 #148; Kvale, 2002 #634}. Organ specific functional status is often assessed by

truments not explicitly developed for critically ill patients. Their reliability has sometimes be questioned. Respiratory problems may persist, especially in ARDS patients, even after

ars after ICU{De Jonghe, 2002 #35}{Flaatten, 2007 #633}.

ncerning non physical impairments, up to 50% of ICU patients suffer pain after

U{Boyle, 2004 #635}. Cognitive disorders are described in half of the general, and in up to of an ARDS population. Half of ICU patients may suffer depression, delusio

orders have been described in 5-64% of patients, depending on the instrument used and on type of patients included{Davydow, 2009 #636; Davydow, 2009 #637}. Younger age, le gender, traumatic and delusional memories of the ICU and previous depression seem k factors associated with their occurrence. The QOL of ICU patients is already reduced

ICU admission, as the functional status, compared to an age- and gender-matched

nths {Dowdy, 2005 #154}. ARDS and traumatic brain injury patients, may take up to 24 nths to stabilize and regain pre-ICU QOL. Even elderly patients seem to recover as fast as unger ICU patients{Hennessy, 2005 #148}.

Commentaire [b1]: Y a‐t‐il une  explication maintenant à cela ? 

(6)

If we look at other outcomes, we have to emphasize that 75-90% of patients surviving ICU, ev

60-80% of the previously working population will be able to go back to their work, however with great differences depending on the ICU admission diagnosis{Dowdy, 2005 #154; Hayes, 20

div ou

Ch

Ch nic critically ill or long-term ICU patients are often defined according to their length of stay ( more than 96 hours (Zilberberg et al., 2008), more than 7 days (Weissman, 2000, Str 28 days (Estenssoro et al., 2006) or more than 30 days(

Fr

phase and who remain dependent on the ICU technology and skills. For the last decade, pro

gro mu

In mo an

unpublished data), but the good news is that a third could be back home. Although the survival rate seems lesser than for general ICU population, chronic critically ill patients seem to

am

en the older ones, will be able to go back to their homes within 12 months after ICU. Up to

00 #141}. There are very few data regarding other areas of major life events, such as orces, violence, economic strains after ICU. Such fields address the patients’ centered tcome too and may deserve more interest in future studies.

ronic critically ills

ro

icker et al., 2003), more than

iedrich et al., 2005)). They can be conceptually defined as patients who survive the acute

bably thanks to the increasing proficiency of intensive medicine, this population has wn fast whereas the number of patients achieving the hospital discharge did not increase as ch (Zilberberg et al., CCM, 2008).

our institution, patients remaining more than 7 days in ICU had higher ICU and hospital rtality (17 and 34 % respectively). On a 3 months follow-up, a third would be dead, other third did stay longer in hospital structure or were institutionalized (personal

achieve a long-term quality of life that seems similar {Stricker, 2005 #39}. However the ount of knowledge regarding this population remains poor.

(7)

El rly patients

Oc characterised by a demographic aging. The proportion of elderly patients is also growing in ICUs. They consume more than half of all ICU days (Angus et al., 20

mo bio (In

their capacity to heal could be somewhat altered and their outcome could be worse than that of

Depending on the definition of elderly patients and after correction of confounding factors, chr

wh of death especially during the

first months (Somme et al., 2003, Kaarlola et al., 2006).

Besi

elderly patients survive ICU stay and their QOL. As for the mortality, the data are difficult to inte

fun t al., 2003), whereas

the self-reported QOL seems to be as good as similar age general population (Ricou and Merlani, 2008). Their recovery rate seems not longer than that of younger patients (Capuzzo et

Finally some studies about elderly patients’ preferences regarding their outcome after ICU see

M de

cidental countries are

00, Pronovost et al., 2001). Elderly patients represent a peculiar population since they are re prone to develop chronic disease such diabetes, hypertension or atherosclerosis. This logical aging progresses in a continuum leading to the development of the frailty syndrome ouye et al., 2007). As a result, elderly patients have a limited physiological reserve and

younger patients after an acute severe illness.

onological age itself has a limited effect on mortality (Boumendil et al., 2007). However, en elderly patients survive ICU, they remain at a high risk

des mortality, the two major questions for this population are the condition in which the

rpret and subject to a pessimistic or optimistic points of view (Hennessy et al., 2005). The ctional status is obviously diminished after an ICU stay (Kaarlola e

al., 2006).

m to suggest that the most unsatisfying issue for them is a discharge to a nursing home.

ost patients are "very unwilling" or "would rather die" (Mattimore et al., 1997). Although

(8)

many suffer of a decreased functional status, most of the elderly ICU survivors are able to go ba

W n be done in ICU to improve long term outcomes after ICU

Two main axes seem to offer possibilities of action to improve the QOL after ICU i.e. the ph

de

#33} and may shorten the recovery phase{Thibault, 2010 #34}. Long-term mortality and prolonged physical impairment are closely related to the ICU acquired paresis {De Jonghe, 20

mo su

#3

to offer some targets to improvement {Jones, 2007 #37}.

Co

Ther

an d housing aspects

{Broomhead, 2002 #31}. At the present state of knowledg , two main axes seem to prevail tha mproving life after ICU: attempts to increase the physical strength and to increase the neuropsychological recovery.

ck to their home and relatively rapidly after their hospital discharge (Conti et al., 2011).

hat ca

ysical strength and the neuropsychological recovery. Increased care for adequate nutrition creases the length of mechanical ventilation and ICU stay{Villet, 2005 #32}{Villet, 2005

02 #35} that may be prevented or treated earlier during the ICU stay by precocious bilization and careful nutrition {Merlani P, 2008 #40}. The neuropsychological outcomes ch as the post traumatic stress disorder impact heavily on patients’ QOL {Granja, 2005

6}. The related associated factors such as prolonged sedation and physical restraints seem

nclusion

e are numerous unrecognized or underestimated problems after ICU regarding physical d psychological recovery, as well as the family, social, employment an

e t would allow i

(9)

Further studies are needed to extend our knowledge about such outcomes and plan future strategies for improvement.

(10)

Figure Legends

e intensivist . Schematic summary of the social and

physicians’ expectations from the intensive medicine thr ghout the years. From a joint refl

Uni

Figure 2: Mortality after ICU.

4 d erent “mortality” moments can be observed: ICI mortality, hospital mortality, first

after rtality compared to an age- and gender-

matched population) and a second after-hospital mortality (with no excess mortality com

fact

matched population. In the “after hospital 2” period the two curbs become parallel, underlying the absence of excess mortality. Only recently there are arguments that the exc

yea

Figure 1

Figure 1: The dream of th

ou

exion between Alexander Mauron bioethician and Bara Ricou intensivist. Bioethics t and Intensive care Unit, University of Geneva, Switzerland.

iff

-hospital mortality (with an excess mo

pared to a matched population). Excess mortality is underlined in the figure by the that the mortality curb of ICU patients has a steeper sloop than the age and gender

ess mortality after ICU, may persist well beyond 1-3 years, and that it may last even 15 rs. (Adapted and modified from 12).

(11)

Figure 2

(12)

Références

Documents relatifs

Our objectives were to compare the characteristics of patients with end-stage renal disease (ESRD) of two French regions (Ile-de-France and Bretagne) and to identify determinants

Our interest in such a model arises from the following fact: There is a classical evolution process, presented for example in [5], to grow a binary increasing tree by replacing at

L’archive ouverte pluridisciplinaire HAL, est destinée au dépôt et à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des

This paper aims to examine the ways in which the British contemporary writer Gabriel Josipovici raises question relating to memory, reminiscence, and commemoration in

Moreover, to support the verbal communication, NAOMI also contains a question-and-answer service, allowing the medical staff to inquire about the (medical) history and lifestyle of

Your station score for ten-minute stations represents how many checklist items you did correctly (80 percent of the station score) and how the examiners rated your performance

The proportion of medical admissions to surgical admissions for the first admission was the same as for the readmission, around 3:1. More than twice as many patients were

We therefore conducted a mul- ticentre retrospective study on such patients in France, reporting both short-term and 1-year mortality and long- term functional status..