Chronic Critical Illness

1. Chronic Critical Illness Jamie McGuire BSN, RN Michelle Lozano BSN, RN

2. Objectives • 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.

3. What is Chronic Critical Illness? • 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)

4. What causes Chronic Critical Illness? • Unknown, specific trigger(s), commonly seen with exacerbation of an underlying chronic illness COPD CRI DM CHF CAD PVD

5. Chronic Critical 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

6. Syndrome of Chronic Critical Illness (Nelson, Cox, Hope, & Carson, 2010)

7. Syndrome of Chronic Critical Illness • 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

8. Syndrome of Chronic Critical Illness • Chronic Respiratory Failure • Brain dysfunction • NM weakness • Endocrinopathies • Malnutrition • Skin breakdown • Sepsis • Symptom Distress • Decreased Functional Status

9. Chronic Respiratory Failure • 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

10. Brain Dysfunction • 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

11. Neuromuscular Weakness • 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

12. Endocrinopathies • 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

13. Malnutrition • Effects: • Neuromuscular weakness • Increased infection • Increased risk for multi-organ dysfunction syndrome (MODS) • Increased incidence of stress ulcers • 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

14. Skin Breakdown • Frequently occur within first 10 ICU days • 40% of Patients • Causes: • Poor nutrition • Anasarca • Shearing forces • Moisture • Immobility • Decreased sensation • Obesity

15. Sepsis • Multiple episodes • “Triple Threat” for infection • Majority of Infections • Line sepsis • Pneumonia • Staphylococcus aureus, Pseudomonas aeruginosa, and other gram negative bacilli • Clostridium difficile colitis

16. Symptom Distress • Defining feature of CCI • Depression • Delirium • Uncontrolled pain • Thirst • Dyspnea • Communication • Multiple interacting symptoms

17. Associated Mortality of CCI • 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

18. Associated Mortality: Factors • Age • Residual organ failure • Prior functional status • Initiating illness • Complications (Sepsis) • Transfer from acute care??

19. Impact on Healthcare • 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

20. Impact on Healthcare • 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

21. Treatment Challenges • Communication • With the patient • With the family of a patient with CCI • Among staff

22. Treatment Challenges • Ineffective Care • Caregiver burnout • Ethics • Research challenges

23. Comprehensive Care Model (Nelson et al., 2010)

24. Comprehensive Care- Ventilator Liberation • 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 • Protocol-driven therapy • RSBI < 80-100 • SBTs • Daily attempts • Multidisciplinary approach • Manage pt. symptoms

25. Comprehensive Care - Function • 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

26. Comprehensive Care - Nutrition • 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

27. Comprehensive Care - Nutrition • 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

28. Comprehensive Care – Infection/Complication Prevention • HANDWASHING • Skin Integrity • Catheter management • Isolation • Nutrition • Bronchial hygiene • Sterile Water • Clorahexadine baths • Single use items • Wexaside/Bleach wipes

29. Comprehensive Care – Palliative Care • 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

30. Comprehensive Care – Palliative Care • 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/Adult-Support/Pages/Chronic-Critical-Illness.aspx • Make family aware of PTSD, depression, and physical health issues that they are at risk for

31. Barriers to Outpatient Care • Determining placement • Medicare reimbursement shapes care • Appropriate staffing for acuity • Continuity of care

32. Local Availability • LTACs • Lifecare Hospitals of Dayton • Kindred • Drake Hospitals of Cincinnati • Rehabilitation Vent/Dialysis • Dayton Rehabilitation Center SNFs • Kensington in Middletown- Vent only   Looking to do vent dialysis • Batavia- Cincinnati- Vent/ dialysis • Baton Rouge- Lima  Vent only • East Galbraith- Cincinnati  Vent/ dialysis • Regency Manor- Columbus  vent /dialysis • Pinnacle Point-  Vent • Essex of Springfield  vent only • Parkside Manor Fairfield Ohio  vent only • Canal   Point  in Cleveland  vent only

33. Question 1 • Which of the following is considered the hallmark of chronic critical illness? • Acute Respiratory Failure < 48 hours • Acute Respiratory Failure > 48 hours • Brain Dysfunction • Acute Kidney Insufficiency 2’ ATN with Acute Hemodialysis

34. Question 2 • 2. Which of the following is a reliable test of thyroid function in the critically ill patient? • T4 • Free T4 • T3 • TSH • None of the above

35. Question 3 • Which of the following drugs is associated with increased incidence of delirium in CCI patients? • Propofol • Midazolam • Fentanyl • Haldol

36. Question 4 • Factors associated with increased M&M in CCI include all of the following EXCEPT • Age • Race • Prior Conditions • Prior Functionality • Initial Insult

37. Question 5 • 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: • Beneficence • Nonmaleficence • Autonomy • Veracity • Lazy nurses

38. References • 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

39. References • Lowe, J., (2009, September). Skin Integrity in critically ill obese patients. Critical Care Nursing, 21(3), 311-v. doi: 10.1016/j.ccell.2009.07.007 • McClave, S., Martindale, R., Vanek, V., McCarthy, M., Roberts, T., Ochoa, J., Napolitano, L., Cresci, G., (2009, May-June). Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and Ameican Society for Parenteral and Enteral Nutrition. Journal of Parenteral and Enteral Nutrition, 33 (3), 277-316. doi: 10.1177/0148607109335234 • Muller, B. (2007, September). Endocrine aspects of critical illness. Annales d’endocronologie, 68(4), 290-298. Retrieved from http://www.sciencedirect.com.ezproxy.libraries.wright.edu:2048/scien ce/article/pii/S0003426607001497 • Nelson, J., & Aluko, H., (2012, June). Integration of palliative care in chronic critical illness management. Respiratory Care, 57 (6). doi: 10.4187/respcare.07624 • Nelson, J., Cox, C., Hope, A., & Carson, S., (2010). Chronic critical illness. American Journal of Respiratory critical care medicine, 182(4), 446-454. doi: 10.1164/rccm.201002- 0210CI • Schulman, R., Mechanick, J., (2012). Metabolic and nutrition support in the chronic critical illness syndrome. Respiratory Care, 57(6), 958-978. doi: 10.4187/respcare.01620