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
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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
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
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
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 ?
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.
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
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
Further studies are needed to extend our knowledge about such outcomes and plan future strategies for improvement.
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).
Figure 2