Transcript Chronic Critical Illness Presentation

Jamie McGuire BSN, RN
Michelle Lozano BSN, RN
• Define chronic critical illness (CCI).
• Identify clinical features of the CCI
syndrome.
• Identify mortality rates associated
with the CCI patient population.
• Identify the impact of CCI on the
healthcare delivery system.
• Identify treatment challenges
associated with CCI.
• Identify barriers to outpatient care
of patients with CCI.
• Definition: A discrete and complex syndrome of physiologic
abnormalities that includes dysfunction of multiple body systems,
a prolonged indeterminate need for high cost acute
interventions, and a high mortality rate
• The advancements of health care delivery as well as the
technological influence within the ICU setting is contributing to a
rise in the number of patients with Chronic Critical Illness (CCI)
(Donahoe, 2012)
• Unknown, specific trigger(s), commonly seen with exacerbation
of an underlying chronic illness
• Requires continued critical care environment for a extended
period of time, usually >14 days
• High associated mortality rates
• Frequent relapses to an unstable condition
• Continued need for advanced medical
and nursing care
• Need for life sustaining medical care
• High risk for disability, distress, and death
(Nelson, Cox, Hope, & Carson, 2010)
• Hallmark of CCI Syndrome is prolonged
dependence of mechanical ventilation
(>2 days – 4 weeks)
• Severe weakness and deconditioning
• Alterations in body composition
• Impaired hormonal balances, impaired
anabolism
• Decreased or impaired immune response
• High risk for multi-drug resistant
organisms
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Chronic Respiratory Failure
Brain dysfunction
NM weakness
Endocrinopathies
Malnutrition
Skin breakdown
Sepsis
Symptom Distress
Decreased Functional Status
• Prolonged mechanical ventilation
• Tracheostomy placed (usually after ~7-10 days of
ET intubation)
• Failure to wean at 60 days indicates that the
patient is unlikely to be weaned from ventilator
• One of the most common forms of organ
failure in CCI
• Associated with increased M&M
• Types: coma, delirium
• Causes:
• Ischemic or traumatic brain injury
• Infection/sepsis, hypotension, hypoxemia,
hyponatremia, hypocalcemia, or azotemia
• Medication side effects
• Sedatives, Analgesics
• Long-term impairment common
• Poor Nutrition
• Medications:
• Neuromuscular blockades, sedation, corticosteroids?
• Inflammation:
• Increases pro-inflammatory cytokines and reactive oxygen species,
leading to muscle proteolysis and loss of muscle protein and mass
• Immobility:
• Decreases muscle protein synthesis, increases muscle catabolism, and
decreases muscle mass, especially in lower extremities
• Impairs microvascular function leading to insulin resistance and
neuromuscular injury
• Causes muscles to switch from slow-twitch fibers to fast twitch, decreasing
endurance
• Stress Hyperglycemia
• Promotion of hepatic glycogenolysis and gluconeogenesis
• Activation of the hypothalamic-pituitary-adrenal axis
• Increased circulating catecholamines
• Increased circulating glucagon and growth hormone
• Iatrogenic
• Decreased Insulin
• Cytokines such as Interleukin-1 and tumour necrosis factor-a
• Thyroid Dysfunction
• Decreased T3, T4, free T4, and TSH in CCI
• Drugs
• Cytokines
• Suppression of thyroid gland by HPA axis
• Malnutrition
• Transport alterations
• Caused by:
• Delays in starting enteral
nutrition
• Inadequate calorie estimates
• Unnecessary holding of
enteral nutrition
• Albumin and Prealbumin
not accurate in the acute
phase of illness
• Evaluate recent weight loss
and nutrient intake prior to
illness, as well as
comparison to IBW
• Effects:
• Neuromuscular weakness
• Increased infection
• Increased risk for multi-organ
dysfunction syndrome
(MODS)
• Increased incidence of stress
ulcers
• Frequently occur within first
10 ICU days
• 40% of Patients
• Causes:
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Poor nutrition
Anasarca
Shearing forces
Moisture
Immobility
Decreased sensation
Obesity
• Multiple episodes
• “Triple Threat” for
infection
• Majority of
Infections
• Line sepsis
• Pneumonia
• Staphylococcus
aureus, Pseudomonas
aeruginosa, and other
gram negative bacilli
• Clostridium difficile
colitis
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Defining feature of CCI
Depression
Delirium
Uncontrolled pain
Thirst
Dyspnea
Communication
Multiple interacting symptoms
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Most expire within six months
Acute care: 20-49%
One-year mortality: 48-68%
Fewer than 12% alive and
independent at 1 year
• 75% of days spent in
institutional care or with
extensive home care
• Survivors have variable
quality of life
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Age
Residual organ failure
Prior functional status
Initiating illness
Complications (Sepsis)
Transfer from acute
care??
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100,000 CCI patients in the US at any point in time
Consume disproportionate number of ICU resources
$20 billion each year OR 13% of all healthcare cost in US
Numbers grow with increasing number of adults >65
receiving advanced, life-saving treatment
Hospital readmission in first year ~40%
Ongoing care after discharge
Family burden increases costs
Cost/benefit high
• Focus on post-acute care
• Decrease Medicare loss to
hospital
• Bed management issues
• Decrease Ineffective
care
• Reduce readmission rates
from LTAC, SNF
• Criteria to stay is limited
• Communication
• With the patient
• With the family of a
patient with CCI
• Among staff
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Ineffective Care
Caregiver burnout
Ethics
Research challenges
• Protocol-driven therapy
• Ventilator Liberation
• Discharged alive and
breathing without
assistance
• 16-37 days
• Affects placement and
reimbursement
• Does not ensure long term
survival, but is independent
indicator
• RSBI < 80-100
• SBTs
• Daily attempts
• Multidisciplinary
approach
• Manage pt. symptoms
• Optimize Physical Function
• Early PT/OT/ST
• Optimize Cognitive Function
• Prompt Evaluation of changes in mental status
• Evaluate risks for delirium
• Limit Sedation Use
• Benzodiazepines
• Cognitive rehab
• Orientation
• Sleep cycle management
• Sensory aides
• Early PT/OT
• Enteral nutrition (EN) is the recommended route
• Decreased Infection, M&M, cost, length of stay, and increased cognitive
function
• START EARLY within first 24-48 hours to goal within 48-72 hours
• Consider
• HOB at 30-45 degrees
• Motility agent
• Continuous post-pyloric feeds
• G-tube, J-tube placement
• Oral hygiene
• Initiation
• Nutritional status
• Comorbid conditions
• Function of the GI tract
• Parenteral Nutrition
• Delay EN feeding when
patient has a MAP of
<60mmHg, during high
dose presser use, and with
s/s of intolerance or
ischemia
• Only after 7days
• Increased infection,
malnutrition, and M&M
• Continue to periodically
attempt EN when
appropriate
• Considerations
• Treat stress
hyperglycemia
• Calcitrol, Vitamin D, zinc
biphosphonate therapy
• Follow-up
• HANDWASHING
• Skin Integrity
• Catheter management
• Isolation
• Nutrition
• Bronchial hygiene
• Sterile Water
• Clorahexadine baths
• Single use items
• Wexaside/Bleach
wipes
• Communication about
care goals
• Maintain consistence with
patient desires
• Slow, incremental approach
to family
• Let the family speak, and
acknowledge emotions
• Interdisciplinary
involvement
• Documentation!!!
• Treat symptom distress
• Depression: SSRIs,
methylphenidate, behavioral
health c/s
• Pain: opioids, alternative
therapies
• Thirst
• Delirium
• Dyspnea: low dose opioids,
fans, alternative therapies
• Communication issues:
Speaking valve, alphabet
board, communication board
• Limitation of Life Support
• Ensure family that patient will not
be abandoned
• Be supportive of decision
• Communicate decision with all
staff
• Clarify odds of survival and or
independent living
• Provide printed information
• http://www.myicucare.org/AdultSupport/Pages/Chronic-CriticalIllness.aspx
• Make family aware of PTSD,
depression, and physical health
issues that they are at risk for
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Determining placement
Medicare reimbursement shapes care
Appropriate staffing for acuity
Continuity of care
LTACs
• Lifecare Hospitals of Dayton
SNFs
• Kensington in Middletown- Vent
only Looking to do vent dialysis
• Kindred
• Batavia- Cincinnati- Vent/ dialysis
• Drake Hospitals of Cincinnati
• Baton Rouge- Lima Vent only
• East Galbraith- Cincinnati Vent/ dialysis
Rehabilitation Vent/Dialysis
• Dayton Rehabilitation Center
• Regency Manor- Columbus vent
/dialysis
• Pinnacle Point- Vent
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Essex of Springfield vent only
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Parkside Manor Fairfield Ohio vent
only
• Canal Point in Cleveland vent only
1. Which of the following is considered the hallmark of chronic
critical illness?
a)
b)
c)
d)
Acute Respiratory Failure < 48 hours
Acute Respiratory Failure > 48 hours
Brain Dysfunction
Acute Kidney Insufficiency 2’ ATN with Acute Hemodialysis
• 2. Which of the following is a reliable test of thyroid function in
the critically ill patient?
a)
b)
c)
d)
e)
T4
Free T4
T3
TSH
None of the above
• Which of the following drugs is associated with increased
incidence of delirium in CCI patients?
a)
b)
c)
d)
Propofol
Midazolam
Fentanyl
Haldol
• Factors associated with increased M&M in CCI include all of
the following EXCEPT
a)
b)
c)
d)
e)
Age
Race
Prior Conditions
Prior Functionality
Initial Insult
• A patient of yours in the ICU on prolonged ventilation is A & O
x3 and responds several times that he does not wish to have
heroic efforts such as CPR and defibrillation performed on him
in the event that he should require such care. The patient codes
the next day and you do not perform CPR. This is an example
of:
a) Beneficence
b) Nonmaleficence
c) Autonomy
d) Veracity
e) Lazy nurses
• Barr, J., Fraser, G., Puntillo, K., Ely, E., Gelinas, C., Dasta, J., Davidson, J.,
…Jaeschke, R. (2013, January). Clinical practice guidelines for the
management of pain, agitation, and delirium in adult patients in the intensive
careunit. Critical Care Medicine, 41(1), 263-306. doi:
10.1097/CCM.0b013e3182783b72
• Donahoe, M., (2012). Current venues of care and related costs for the chronic critically ill.
Respiratory Care, 57(6), 867-886. doi:
10.4187/respcare.01656
• Economidou, F., Douka, E., Tzanela, M., Nanas, S., & Kotanidou, A. (2011, April-June).
Thyroid function during critical illness. Hormones, 10(2), 117-124. Retrieved from
http://www.hormones.gr/723/article/article.html
• Fan, E., (2012). Critical illness neuromyopathy and the role of physical therapy and
rehabilitation in critically ill patients. Respiratory Care, 57(6), 933-944. doi:
10.4187/respcare.01634
• Girard, T., (2012, June). Brain dysfunction in patients with chronic critical illness.
Respiratory Care, 57(6), 947-957. doi: 10.4187/respcare.01708
• Kahn, J., Werner, R., David, G., Have, T., Benson, N., & Asch, D. (2013). Effectiveness of
long-term acute care hospitalization in elderly patients with chronic critical illness.
Medical Care, 1(51), 4-10. doi: 10.1097/mlr.06013e3e31828fe07c
• Loss, S., Marchese, C., Boniatti, M., Wawrzeniak, I., Oliveira, R., Nunes, L. &
Victorino, J., (2013). Prediction of chronic critical illness in a genreal intensive care
unit. Revista de Associacao Medica Brasileira, 59(3), 241-247. doi:
10.1016/j.ramb.2012.12.002
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