Transcript Critical Care: A Pyrrhic Victory?

Critical Care: A Pyrrhic Victory?
Johnny Isenberger RN, MSN, ACNP-BC, CCRN
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https://echo.umassmed.edu:8443/ess/echo/presentation/771fde2c-cf24-4eb6bcb4-66d1ddb12b84
I have no financial disclosures or conflicts of interest
Objectives
1. Describe post intensive care syndrome (PICS)
2. Discuss impact of PICS on patients and families
3. Discuss risk factors, etiologies and impact of delirium and ICU acquired
weakness
4. Discuss ABCDEF mnemonic for ICU liberation
5. Discuss available resources for families
If we are victorious in one more battle with the Romans, we shall be utterly ruined"
“Victims” of Critical care
PICS (Post intensive care syndrome)
Crit Care Med 2012 Vol. 40, No. 2
Impact
Increased mortality
Signs of dementia
Impairment in spirometry, lung volumes and
diffusion capacity (can be >= 5 yrs)
Reduced quality of life
Reduction in employment
Muscle atrophy
Depression
Impairment in activities and instrumental activities of
daily living and 6-min walk distance
PTSD
Decreased memory, attention, and executive function
Anxiety
Alcohol and opioid misuse
Cognitive dysfunction
Crit Care Med 2016; 44:954–965
Crit Care Med 2016; 44:869–879
Crit Care Med 2011; 39:371–379
Brain ICU study
821 patients
Examined the long term cognitive effects of critical illness in patients admitted to medical or surgical
ICUs with shock and/or respiratory failure requiring mechanical ventilation
Baseline 6% of patients had cognitive dysfunction, at 3 months up to 40% had dysfunction similar to
those with moderate TBI; 26% similar to dementia
37% of patients experienced symptoms of depression
32% of patients were disabled in their activities of daily living at three months, 26% were disabled in instrumental
activities of daily living, disability was prominent in those with and without pre-existing functional disability, and these
disabilities persisted in most patients at 12 months.
N Engl J Med. 2013;369(14):1306.
Patient testimonials
weakness and neuropsychological impairment
patient testimonial
Risk factors
Pre-existing
Psychiatric
Cognitive
ICU related
Use of benzodiazepines
ARDS
Sepsis
Delirium
Trends Mol Med. 2014
Apr;20(4):234-8
ICU acquired weakness
JAMA. 2010;304(16):1787-1794
Delirium
A 87 year old female, admitted with health-care associated pneumonia
(MRSA), has been in the ICU for about one week. History includes CHF,
hypothyroid, GERD, hard of hearing, and uses glasses. She is intubated,
sedated, and restrained.
Current medications: Hydrocortisone 50 mg IV every 8 hours (weaning);
versed at 2 mg/hr, fentanyl at 50 mcg/hr; vancomycin 1 gram IV daily; pepcid
20 mg IV daily.
What is delirium and how is it “discovered?” What further information would
you need in this particular case?
What risk factors does she have for the development of delirium?
What medications can lead to delirium?
What medications can be used to prevent or treat delirium?
What strategies can be used to prevent delirium?
ICU acquired weakness
Same 87 year old woman is now 1 month into her ICU stay. She is trached
and has a PEG tube. She is not participating in spontaneous breathing trials
and has never tolerated being off the vent. She can barely lift her legs on her
own.
Why is she weak?
What risk factors does she have for ICU acquired weakness?
So what can ICU providers do…..
ABCDEF protocol
ICU diaries
Metabolic control
Its all about the ABC’s and DEF
Mnemonic developed by the ICU delirium group in Vanderbilt
Includes important elements of the new Pain, Agitation, and Delirium practice
guidelines published by the Society of Critical Care Medicine
ICUdelirium.org
Assess, Prevent, and Manage Pain
Analgesia first sedation
Assessment: Critical Care Pain Observation scale, numerical scale
Prevention: Pre-procedural analgesia
Treatment: Multimodal approach
Both SAT and SBT
The Wake Up and Breathe study
Pairing together daily SATs with daily Spontaneous Breathing Trials (SBTs) in a
protocol that included safety screens and failure criteria resulted in:
A) decreased time on the ventilator
B) reduced time spent in the ICU and hospital
C) improved one-year survival
Also stressed the importance of coordinating care with multiple disciplines
Choice of analgesia and sedation
Assessment of sedation: Targeted sedation with RASS assessment. Need to
establish a goal
If RASS > 0, assess and treat pain first. Consider non-benzodiazepines, unless
ETOH or benzodiazepine withdrawal is suspected
If RASS < -2, hold sedation and resume at 50% if still need
Treat pain first and avoid benzodiazepines
Anesthesiology. 2006 Jan;104(1):21-6.
ICUdelirium.org
Assess delirium
Duration of delirium which predicts outcome
Increase in mortality
Increase in hospital length of stay
Increase in costs
N Engl J Med. 2013;369(14):1306
Intensive Care Med 2001; 27:1892-1900
JAMA. 291(14): 1753-1762, 2004.
Early Mobility and Exercise
Early mobility is safe and well tolerated
Results in better functional outcomes at hospital discharge
Shorter duration of delirium
More ventilator-free days compared with standard care.
Shorter duration of ICU stay
Better functional mobility at hospital discharge
Family engagement and empowerment
Critical illness is a life changing event for family members
PTSD and anxiety common
They want communication
Comfortable physical environment
Identify family distress
Support groups
JBI Database System Rev Implement
Rep. 2016 Mar;14(3):181-234. doi:
10.11124/JBISRIR-2016-2477
ICU diaries
Reduce PTSD symptoms
Allows patients to recall missing days
Metabolic control
Propranolol reverses catabolism and leads to tissue healing in burns. Can it
work in general critical care patient?
Will oxandrelone work?
Continue glycemic control
Curr Opin Crit Care. 2016 Aug;22(4):325-31. doi:
10.1097/MCC.0000000000000330
N Engl J Med. 2001 Oct 25;345(17):1223-9
J Burn Care Res. 2009 Nov-Dec;30(6):1013-7. doi:
10.1097/BCR.0b013e3181b48600.
Treatment
Multidisciplinary effort
Good communication between in-hospital providers and
outpatient/rehabilitation providers.
Support groups
PICS clinics: UK and USA (Vanderbilt).
Resources
Thrive network - SCCM
ICU survivors share their story
Click on the link below to complete the evaluation
and obtain your contact hour certificate
https://survey.zohopublic.com/zs/CziuDN