Transcript Chronic Critical Illness - Allison Tayloe MS, RN, AG

Chronic Critical Illness
Allison Tayloe RN, BSN, CCRN
Brooke Harris RN, BSN, CCRN
Katie Kearney RN, BSN, CEN
RaeAnne Fondriest RN, BSN
Objectives
 Define chronic critical illness
 Identify the characteristics of chronic critical
illness
 Discuss preventative/protective measures
against chronic critical illness
 Examine the appropriate treatment goals as
they relate to chronic critical illness
 Recognize long term implications related to
chronic critical illness
Definition
 Chronic critical illness first
termed by Girard & Raffin in
1985 in an article titled “ to
save or let die?” pertaining to
patients who had failed to
wean from mechanical
ventilation for a prolonged
period of time in the intensive
care unit.
 These patients neither
recovered nor died, but were
rather “stuck” in a chronically
ill state requiring continuous
care.
(Nelson et al., 2010; Image from Google Images)
Definition
o Chronic critical illness is a syndrome characterized by
neuroendocrine dysfunction, malnutrition,
multisystem organ dysfunction, and symptom
distress (Cox, 2011).
Acute injury/
illness
Acute stress
response
Failure to wean
from ventilator
CCI
Depletion of
physiologic
reserve
Image from Google Images
Neuroendocrine
and
inflammatory
response
Characteristics of CCI
 Hallmark of CCI is an inability to be weaned from
prolonged mechanical ventilation (Cox, 2011).
 There is a positive correlation between length of
mechanical ventilator (prolonged mechanical ventilation)
time and associated mortality with CCI.
 Even after liberation from mechanical ventilator,
continued functional dependence key finding in those
with CCI (Nelson et al., 2010).
Characteristics of CCI
 Mechanical ventilation 2
days- 4 weeks
 Profound weakness
 Alterations in body
composition
including:
 Decreased muscle
mass
 Anasarca
 Increased adipose
tissue
 Neuroendocrine changes
 Decreased hormone
levels
 Increased anabolism
(Nelson et al., 2010)
 Increased susceptibility
to infections
 Brain dysfunction
 Coma
 Delirium
 Prolonged Immobility
 Inability to communicate
 Inducing stress,
anxiety, depression
for patient
(Adapted from Nelson, 2010)
Key Facts of CCI
 Chronically critically ill ( CCI) accounts for ~ 5-10% all
ICU admissions.
 CCI patients reach nearly ~90,000 discharges yearly.
 Majority of patients > 65 years of age.
 The number and severity of patients with CCI is expected
to continue to rise over the next ten years.
 One year survival for those with CCI remains low
(between ~20-40%).
 Financial burden associated with CCI is continually rising,
but can be lessened with appropriate transfer out of the
hospital ICU setting.
(Carson, 2005)
Economic Impact of Chronic
Critical Illness
 Annually cost are estimated to be $24 billion
 $76K-$2Mill. Per patient
 The Critically ill only account for $7400-$24K
 Ventilators as a whole account for 1/3 healthcare cost in
US hospitals
 Requiring intubation nearly double individual healthcare
cost
 Number of those requiring mechanical ventilation is expected to
triple by the year 2020
 Only 5-10% of ICU patient account for 30-50% of
resources used
 ECF play an important role in reduction of length of stay,
however costs remain high.
(Weinck & Winkelman, 2010)
(Adapted from Carson, 2012)
Populations at risk
Post-op complications from major cardiac or abdominal surgeries
Trauma patients
Patients with acute exacerbation of chronic lung disease
Patients with previous diagnosis of neurologic disease
Patients with multiple co-morbidities ( especially cardiac, pulmonary, and renal
disease)
Complications leading to prolonged mechanical ventilation time
Patients with neuromuscular abnormalities
Greatest risk factor: Patients with SIRS (systemic inflammatory response
syndrome) and/or sepsis
(Carson, 2005)
Acute versus Chronic Critical Illness
ACUTE
Elevated ACTH,
cortisol, and
prolactin levels
Increase growth
hormone levels
Decreased ACTH
levels
Decrease thyroid
stimulating hormone ,
T3, & T4
Mechanical Ventilation
>21 day, growth
hormone decreases
Neuroendocrine
changes are often
maladaptive causing
protein deficiencies,
insulin resistance,
hypertriglyceridemia,
& decrease immune
function
Decreased
thyrotropic and
gonadotropic
hormone levels
Neuroendocrine
changes are
adaptive to
preserve vital
organs and
function
CHRONIC
(Carson, 2005)
Hormones
 ACTH- releases cortisol
 Typically released in times of
stress
 Associated with
hyperglycemia by
gylcogenesis, increased
gluconeogenesis
 Assists in breakdown of
amino acids and protein,
increasing lactate
 Stimulates release of
triglycerides, free fatty acids
 Impaired wound healing
(Shimmer & Funder, 2011;Image from Google Images)
Pathophysiology Acute Phase
 Elevation in adrenocorticotropic hormone (ACTH),
cortisol, and prolactin levels
 Decrease in thyrotropic and gonadotropic hormone levels
 Pituitary gland increases secretion of growth hormone in
a steady pulsing pattern controlled by gonadotropin
releasing hormone (GNRH)
 The alterations in hormones enhance the body’s
response to maintenance of vital organ and immune
function
(Carson, 2005)
Pathophysiology- Chronic Phase
 Decrease in ACTH along some anterior pituitary hormone
levels
 Elevated cortisol level continues
 Loss of thyroid stimulating hormone (TSH) leading to a
decrease triiodothyroxine (T4) and triiodothronine (T3)
 Decrease in both excretion and pattern regulararity of
GH secretion
 Alterations in hormones are detrimental to body’s
function leading to decrease in protein production and
progressive protein breakdown
(Carson, 2005)
(Used with permission from Van den Berghe G, de Zegher F, Bouillon R: Acute and prolonged critical illness as
different neuroendocrine paradigms. J Clin Endocrinol Metab 83:1827, 1998.)
Management of Chronic Critically Ill
Patients
Image from Google Images
Management of CCI Patient
Multi-factorial
Prevention
• Mechanical Ventilator Weaning/Mobility
• Nutrition
• Functional & Cognitive Recovery
• Preventing Complications
• Care Models
• Ethics
(Carson, 2005)
Management of CCI
 Requires an interdisciplinary approach
 Consistency of providers proves beneficial
 Involves patient, their family, ICU physician, ICU staff (RN,
RT, & Social work)
 May also include chaplain, palliative care, ethics committee
 Patient and family should know the caregivers prior to any
potential family meeting
 With prior relationship care team members may be able to
recognize change in patient and family’s emotional status more
quickly.
(Nelson & Hope,
2012).
Recognize those at risk…
 ProVent Score mortality prediction model
 Looks at 4 variables to identify patients at high risk for one
year mortality
 Age
 Platelet count
 Hemodialysis
 Vasopressor Requirement
 Used to help clinicians establish prognosis
 Is not reliable for functional outcomes, therefore doesn’t
provide much reassurance for family members
(Carson, 2012).
ABCDE Bundle
 Functional & Cognitive Recovery
 ABCDE Bundle was initiated in response to complication secondary to long
term mechanical ventilation, delirium, and exacerbated weakness
 ABCDE= spontaneous awakening and breathing trials coordination,
delirium monitoring and management, and early mobility
 Based on three main principles
 Improved communication & collaboration of the healthcare team
 Standardize care processes
 Break the cycle of over sedation &
prolonged mechanical ventilation.
(ABCDE Bundle, 2012; Balas et
al., 2012 ).
ABCDE Bundle
 A= awaken patient every day, sedation weaned
 Nursing implement sedation protocols and algorithms
 Richmond agitation and sedation scale (RAAS)
 B= breathing
 Spontaneous breathing trials (SBT’s)
 Most institutions these trials occur daily
 Certain parameters must be met for patients to “qualify”
 FiO2 < 60%
 SBP > 90 mm Hg, not actively titrating vasopressors
 Peep < 8
 SBT’s have been shown to
 Decrease ventilator time
 Decrease length of ICU and overall hospital stay
 decrease PTSD from chronic critical illness
 C= coordination
 Awakening and breathing trials should be performed together
 Decreased ventilator time
 Decreased coma
 Decreased ICU stay when SAT and SBT’s coincide
(Balas et al., 2012).
http://www.aacn.org/WD/CETests/Media/ABCDE--Tools%20for%20Implementation.pdf
Figure 1. Richmond Agitation and Sedation Scale (RASS) (Sessier et al. 2002). Reprinted with permission.
Retrieved from http://www.medscape.com/viewarticle/708387_3
ABCDE Bundle
 D= Delirium monitoring management
 Confusion Assessment Method (CAM)
 Based on four categories: fluctuating course of
mental status, inattention, altered level of
consciousness, and disorganized thinking.
 Intensive Care Delirium Screening Checklist
 Based on 8 categories similar to CAM.
 E= Early Mobility
 PT/OT, out of bed, ambulation
 Mobility progression protocols
 Usually based on similar criteria to SBT’s
(MOVE)
 Myocardial stability = (no arrhythmia or
recent MI)
 Oxygen = FiO2 <60%
 Ventilation= PEEP < 10 cm H20
 Engages to voice = (follows command )
www.aacn.org
Figure 2. CAM-ICU Flowsheet. © 2002 E. Wesley Ely MD, MPH and Vanderbilt University. All rights reserved. Retrieved
from www.icudelirium.org
Research Walk To Wean
 Walk to Wean
 104 patients were studied and
randomized electronically
 49 intervention: Daily sedation
vacation and early exercise &
mobilization
 55 control: Daily sedation
vacation and physician ordered
therapy
 Primary Outcome
 Independent Status:
Performing six activities of
daily living & walking
 Secondary Outcome
 Number of Delirious days
 Number of Ventilator free
days in 28 day period
(Schweickert, 2009; Image from Google Images)
Research Walk to Wean cont.
 Walk to Wean Trial Outcomes
 Therapy only discontinued for 4
patients related to instability
 Primary Intervention Group
 Improved outcomes in functional
status (59% vs 39%)
 Secondary Intervention Group
 Fewer delirium days (2 days vs. 4
days)
 Fewer ventilator days
vs. 23.5 days)
(21.1 days
(Schweickert, 2009; Image from Google
Images)
Tracheostomy: To do or not to
do?
Advantages
Disadvantages
Timing/Indications
Decannulation
•Decreased ventilator dependent time
•Shorter ICU stay
•May be an unnecessary procedure if done too
quickly
•Bleeding, infection
•Fistula formation
•Failure to wean from mechanical ventilation (10-14
days)
•Inability to handle excessive secretions
•Neurologic dysfunction
•Spontaneous breathing trials via tracheostomy
mask
•Assess for airway swelling and inflammation prior
to decannulation
(Saint, Madding, Calfee, Kolwaski, Kresn 2010; O’Conner & White, 2010)
Criteria for Decannulation
 The disease process that resulted in the need for a
tracheostomy should be resolved
 Patient should be alert and able to follow commands
 Effective cough
 Able to swallow and manage own secretions
 Airway patency
 Evaluate using a mirror exam of the larynx or by direct
fiberoptic endoscopy
 Observe patient’s respiration when tube is occluded
 Plugging
(Yu, 2012; Conner & White, 2010)
Nutrition
 Malnutrition common in ~ 40% of critically ill patient
 Goal in CCI is to avoid malnutrition (over/under nourished)
 Aimed at prevention of body mass loss, prevention of tissue and immune
response alteration
 Protein-calorie malnutrition along with decreased albumin levels directly
links to elevated levels morbidity & mortality
 Monitoring of Prealbumin correlates to current nutritional status, where
albumin is related to long term nutritional status
Nelson & Hope, (2012); Schulman &
Mechanick (2011)
Nutrition
 Underfeeding
 Improper protein levels increase
metabolic consumption leading
to less energy reserves
 Linked to increase risk of
infection, longer hospital stays &
mechanical ventilation, elevated
risk of death
 Overfeeding
 Improper Carbohydrate, lipid,
and protein levels lead to
increased organ dysfunction
secondary to elevated metabolic
demand
 Similar to effects of underfeeding
along with liver/renal failure
Schulman & Mechanick (2011).
Nutrition
 Refeeding Syndrome
 Occurs following initiation of nutrition in severely malnourished patient
 Can lead to altered diaphragmatic function
 Decreased levels of insulin & glucagon
 Leading to alteration of metabolism
 Increased lipolysis, free fatty acid oxidation, & ketones
 Worsening of electrolyte abnormalities
 Due to depletion of already low levels of phosphate, insulin, and thiamine
 Goal with feeding:
 20-25 kcal/kg/day
 AjBW= IBW + [(ABW-IBW) – correction factor]
(Schulman & Mechanick 2011; Image from Google Images)
Nutrition
 ACNP should
 Complete detailed evaluation of nutritional status and
protein wasting
 Checking CBC, ammonia, hgbA1c, albumin/pre-albumin
 Thyroid function studies, urea nitrogen
 Optional testing
 Testosterone, iron studies (ferritin, iron, transferrin saturation,
iron binding capacity),serum cortisol
(Mechanick & Brett, 2005; Ogilvie & Fitzsimons, 2012;
Images from Google Images)
Functional Cognitive Recovery
 Physical/Occupational Therapy
 Walk to wean
 Early Mobility (ABCDE Bundle)
 Avoid use/overuse of Benzodiazepines
 Recommend use of new age antipsychotics such as
Haloperidol
 Long Term Cognitive Recovery
Neuro-Cognitive Dysfunction
 Coma and delirium results in recurrent psychiatric and
cognitive behavior changes which can be persistent long
after discharge
 Impairment can be cause by:
 Degree of illness
 Medications
 Inability to communicate with providers
 Psychological needs not being met
 Pain, Thirst, Dyspnea
 Can lead to anxiety and depression
 Alterations in sleep patterns
 Approximately 15-20% suffer from post traumatic stress in
relation to their CCI
Wienck & Winkelman, 2010
Complications
 Triple threat risk of
infection
 Barrier breaches: IV
catheters & Skin
breakdown
 Treatment
 Hand hygiene
 Exposure to resistance
organism within acute
care hospital setting
 Contact precautions
 “Immune Exhaustion”
 Limit use of antibiotics
 Recent critical illness
and history of comorbidities
(Carson, 2005; Images from Google Images)
 Early removal of invasive
catheters
 Maintain skin
Complications from CCI
Deficit
Reduction
Act of
2005
• Mandated strict compliance aimed at
prevention of hospital acquired infections
• NO reimbursement for conditions such as:
• Urinary Tract Infection
• Central Line Associated Blood Stream
Infection
• Decubitus Ulcers
• Preventable Events (Blood incompatibilities)
• Falls
• Glycemic Control
• Post operative Infection
• Deep Venous Thrombosis
• If not documented as present on admission
(www.cms.gov, 2012)
Nosocomial Infections
Prevention is Key
Pressure Ulcers
CLABSI (central line
associated blood
stream infection)
CAUTI (catheter
associated urinary
tract infection)
(Wachter, 2012)
•Only way to prevent these infections is not to place lines or
have patients who are immobile (impossible)
•Adequate nutrition (protein)
•Early mobility
•Incontinence care
•Often needed for vasopressors, IV antibiotics, anti-arrhythmic
•Sterile technique during line placement and dressing changes
•Remove as soon as possible
•Nurses need an order to place a foley catheter
•When needed, remove as soon as possible
Ethics
 Autonomy
 Presumption patient can make own decisions
 Autonomy versus decision-making capacity
 Cognitive function and delirium most influence patient’s
ability to make decisions in CCI.
 A research study found that patients who are hospitalized
with poor physical functioning have cognitive function level
less than that of a 10 year old
(Teneli et al., 2010; Images from Google images)
Ethics
 Justice
 In the United States, critical care (ICU) accounts for 20% of
all health costs and 1% of the gross national domestic
product (14% of GDP is spent on healthcare)
 Barriers to reducing cost in ICU
 Fixed costs
 Inability to accurately predict ICU mortality
 Inability to predict unexpected outcomes
(Luce & Rubenfeld, 2002, Connors & Dawson, 1995;
Image from Google Images)
Ethics/Justice Study
 SUPPORT is a landmark study to understand prognoses
and preferences for outcomes and risks of treatment.
The study followed a large group of critically ill patients
with a six month predicted survival probability of 52%.
SUPPORT identified several areas for improvement:
 Significant lack of communication, only 47% of physicians
knew if their patients preferred CPR
 Establishing DNR orders for terminal patients earlier. Many
patients that died spent at least 10 days in the ICU
comatose, on mechanical ventilation, in pain with 46% of
DNR orders written two days before death.
 Most expensive patients to treat were those classified as
medium-risk patients on admission, those who had a 5170% estimated two month survival and those with
unexpected outcomes
(Luce & Rubenfeld, 2002, Connors & Dawson, 1995)
Ethics
 Non-Maleficence & Beneficence
 Non-Maleficence deals with idea of doing no harm and
beneficence deals with the idea of doing good
 In a survey of critical care physicians 87% reported they
felt futile care had been delivered in the ICU in the past
year
 Critical care physicians reported believing 11% of
patients receiving care that was futile and 8.6 % were
receiving care that was highly likely to be futile
 Of the 11% of patients receiving care believe to be futile
68% died before discharge and at six months there was an
85% mortality rate
(Huynh et. al., 2013).
Ethics-Moral Distress
 Moral Distress
 Research shows that the most distressing phenomenon
reported by caregivers in end-of-life care is the delivery of
futile care, organ donation and pain management
 Some nurses report experiencing moral distress weekly
 Research shows a positive correlation between knowledge
of moral ethics and reported distress over ethical issues
 Futile care
 Factors Influencing Perception Healthcare is Futile:
 burden outweighed benefit
 treatment did not align with patient’s goals
 Death was imminent
(Browning, 2013,Weigand & Funk, 2012)
Palliative
Care
 Ongoing, highly proactive communication with patient
and families
 Knowledge/Discussion of Living well
 Acknowledges belief systems
 Lessens family burden
 Acknowledges spiritual, physical, & emotional need
 Promotes long-term health and well being
(Nelson, Cox, Hope, & Carson, 2010; Image from Google images)
The Patient’s Perception
Self-reported symptom experience of
critically ill cancer patients receiving
intensive care
Objective: To characterize the symptom experience
of 100 ICU patient’s with the diagnosis of terminal
cancer and high risk for hospital mortality.
Measurements: Patients’ self-reports of symptoms
using the Edmonton Symptom Assessment Scale
(ESAS), and ratings of pain or discomfort associated
with ICU diagnostic/therapeutic procedures and of
stress associated with conditions in the ICU.
(Nelson et al., 2001)
Results
 Hospital mortality for the group was 56%
 100% provided symptom reports
 55% and 75% reported experiencing pain,
discomfort, anxiety, sleep disturbance, or
unsatisfied hunger or thirst that they rated as
moderate or severe.
 Depression and dyspnea at these levels were
reported by approximately 40% and 33% of
responders.
 Significant pain, discomfort, or both were
associated with common ICU procedures but well
managed
 Inability to communicate, sleep disruption, and
limitations on visiting were particularly stressful
among ICU conditions studied.
Nelson et al., 2001)
Family Burdens
 High rates of:
 Depression
 Financial hardship
 “Care-giver overload”
 Studies have shown:
 Depression is more severe in
families
(Carson, 2005; Image from Google Images)
(Image from Google Images)
1. An acute care nurse practitioner is deciding
whether to recommend a long-term medication
regimen that will help a patient manage chronic
disease symptoms but may also introduce
problematic side effects. This decision reflects
which ethical principle?
A. Beneficence
B. Autonomy
C. Fidelity
D. Justice
1. An acute care nurse practitioner is deciding
whether to recommend a long-term medication
regimen that will help a patient manage chronic
disease symptoms but may also introduce
problematic side effects. This decision reflects
which ethical principle?
A. Beneficence
B. Autonomy
C. Fidelity
D. Justice
2. Delirium, an acute confusional state, is a
common disorder that remains a major cause of
morbidity and mortality in the United States. Which
of the following patients is at highest risk for
developing delirium?
A. A 55-year-old man postoperative day two from a
total colectomy
B. A 68- year- old woman admitted to the ICU on a
ventilator for acute COPD exacerbation
C. A 74 -year -old woman in the preoperative clinic
before hip surgery
D. An 84- year -old man living in an assisted living
facility
2. Delirium, an acute confusional state, is a common
disorder that remains a major cause of morbidity and
mortality in the United States. Which of the following
patients is at highest risk for developing delirium?
A. A 55-year-old man postoperative day two from a
total colectomy
B. A 68- year- old woman admitted to the ICU on a
ventilator for acute COPD exacerbation
C. A 74 -year -old woman in the preoperative clinic
before hip surgery
D. An 84- year -old man living in an assisted living
facility
3. Which of the following patients is at lowest risk for
the development of chronic critical illness?
A. Unrestrained trauma patient in a MVC
B. 39- year-old patient following an elective knee
surgery who was recently extubated
C. Patients with neuromuscular disorders
D. Patient developing SIRS after being admitted to
the ICU for pneumonia
3. Which of the following patients is at lowest risk for
the development of chronic critical illness?
A. Unrestrained trauma patient in a MVC
B. 39- year-old patient following an elective knee
surgery who was recently extubated
C. Patients with neuromuscular disorders
D. Patient developing SIRS after being admitted to
the ICU for pneumonia
4. Which of the following criteria would exclude a
ventilated patient from early mobilization?
A. Patient on cardiac monitor with a NSR of 96
B. Patient able to follow commands but is CAM
positive
C. PEEP of 8 cm H2O
D. FiO2 of 70%
4. Which of the following criteria would exclude a
ventilated patient from early mobilization?
A. Patient on cardiac monitor with a NSR of 96
B. Patient able to follow commands but is CAM
positive
C. PEEP of 8 cm H2O
D. FiO2 of 70%
5. Which of the following is the hallmark biochemical
feature in refeeding syndrome?
A. Increased secretion of glucagon
B. Hyperkalemia
C. Hypophosphatemia
D. Hypermagnesemia
5. Which of the following is the hallmark biochemical
feature in refeeding syndrome?
A. Increased secretion of glucagon
B. Hyperkalemia
C. Hypophosphatemia
D. Hypermagnesemia
References
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