Chronic critical illness: are we saving patients or creating victims?

Sergio Henrique Loss, Diego Silva Leite Nunes, Oellen Stuani Franzosi, Gabriela Soranço Salazar, Cassiano Teixeira, Silvia Regina Rios Vieira, Sergio Henrique Loss, Diego Silva Leite Nunes, Oellen Stuani Franzosi, Gabriela Soranço Salazar, Cassiano Teixeira, Silvia Regina Rios Vieira

Abstract

The technological advancements that allow support for organ dysfunction have led to an increase in survival rates for the most critically ill patients. Some of these patients survive the initial acute critical condition but continue to suffer from organ dysfunction and remain in an inflammatory state for long periods of time. This group of critically ill patients has been described since the 1980s and has had different diagnostic criteria over the years. These patients are known to have lengthy hospital stays, undergo significant alterations in muscle and bone metabolism, show immunodeficiency, consume substantial health resources, have reduced functional and cognitive capacity after discharge, create a sizable workload for caregivers, and present high long-term mortality rates. The aim of this review is to report on the most current evidence in terms of the definition, pathophysiology, clinical manifestations, treatment, and prognosis of persistent critical illness.

Conflict of interest statement

Conflicts of interest: None

Figures

Figure 1
Figure 1
Injury, allostasis and allostatic overload. CCI - chronic critical illness.

References

    1. Kelly FE, Fong K, Hirsch N, Nolan JP. Intensive care medicine is 60 years old: the history and future of the intensive care unit. Clin Med (Lond) 2014;14(4):376–379.
    1. Reisner-Sénélar L. The birth of intensive care medicine: Björn Ibsen's records. Intensive Care Med. 2011;37(7):1084–1086.
    1. Zimmerman JE, Kramer AA, Knaus WA. Changes in hospital mortality for United States intensive care unit admissions from 1988 to 2012. Crit Care. 2013;17(2):R81–R81.
    1. Girard K, Raffin TA. The chronically critically ill: to save or let die? Respir Care. 1985;30(5):339–347.
    1. Daly BJ, Rudy EB, Thompson KS, Happ MB. Development of a special care unit for chronically critically ill patients. Heart Lung. 1991;20(1):45–51.
    1. Clochesy JM, Daly BJ, Montenegro HD. Weaning chronically critically ill adults from mechanical ventilatory support: a descriptive study. Am J Crit Care. 1995;4(2):93–99.
    1. Nierman DM, Nelson JE. Chronic critical illness. Crit Care Clin. 2002;18(3):xi–xii.
    1. Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical illness. Am J Respir Crit Care Med. 2010;182(4):446–454. Review.
    1. Nelson JE, Meier DE, Litke A, Natale DA, Siegel RE, Morrison RS. The symptom burden of chronic critical illness. Crit Care Med. 2004;32(7):1527–1534.
    1. Douglas SL, Daly BJ. Caregivers of long-term ventilator patients: physical and psychological outcomes. Chest. 2003;123(4):1073–1081.
    1. Loss SH, Marchese CB, Boniatti MM, Wawrzeniak IC, Oliveira RP, Nunes LN, et al. Prediction of chronic critical illness in a general intensive care unit. Rev Assoc Med Bras (1992) 2013;59(3):241–247.
    1. Wiencek C, Winkelman C. Chronic critical illness: prevalence, profile, and pathophysiology. AACN Adv Crit Care. 2010;21(1):44–61. quiz 63.
    1. Girard TD. Brain dysfunction in patients with chronic critical illness. Respir Care. 2012;57(6):947–955.
    1. Kahn JM, Le T, Angus DC, Cox CE, Hough CL, White DB, Yende S, Carson SS, ProVent Group Study Investigators The epidemiology of chronic critical illness in the United States. Crit Care Med. 2015;43(2):282–287.
    1. Scheinhorn DJ, Hassenpflug MS, Votto JJ, Chao DC, Epstein SK, Doig GS, Knight EB, Petrak RA, Ventilation Outcomes Study Group Ventilator-dependent survivors of catastrophic illness transferred to 23 long-term care hospitals for weaning from prolonged mechanical ventilation. Chest. 2007;131(1):76–84.
    1. Carson SS, Kahn JM, Hough CL, Seeley EJ, White DB, Douglas IS, Cox CE, Caldwell E, Bangdiwala SI, Garrett JM, Rubenfeld GD, ProVent Investigators A multicenter mortality prediction model for patients receiving prolonged mechanical ventilation. Crit Care Med. 2012;40(4):1171–1176.
    1. Boniatti MM, Friedman G, Castilho RK, Vieira SR, Fialkow L. Characteristics of chronically critically ill patients: comparing two definitions. Clinics (São Paulo) 2011;66(4):701–704.
    1. Zilberberg MD, Luippold RS, Sulsky S, Shorr AF. Prolonged acute mechanical ventilation, hospital resource utilization, and mortality in the United States. Crit Care Med. 2008;36(3):724–730.
    1. MacIntyre NR, Epstein SK, Carson S, Scheinhorn D, Christopher K, Muldoon S, National Association for Medical Direction of Respiratory Care Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference. Chest. 2005;128(6):3937–3954.
    1. Daly BJ, Douglas SL, Kelley CG, O'Toole E, Montenegro H. Trial of a disease management program to reduce hospital readmissions of the chronically critically ill. Chest. 2005;128(2):507–517.
    1. Nierman DM. A structure of care for the chronically critically ill. Crit Care Clin. 2002;18(3):477-91, v.
    1. Carson SS, Bach PB. The epidemiology and costs of chronic critical illness. Crit Care Clin. 2002;18(3):461–476.
    1. Nasraway SA, Button GJ, Rand WM, Hudson-Jinks T, Gustafson M. Survivors of catastrophic illness: Outcome after direct transfer from intensive care to extended care facilities. Crit Care Med. 2000;28(1):19–25.
    1. Douglas SL, Daly BJ, Brennan PF, Harris S, Nochomovitz M, Dyer MA. Outcomes of long-term ventilator patients: a descriptive study. Am J Crit Care. 1997;6(2):99–105.
    1. Cohen IL, Booth FV. Cost containment and mechanical ventilation in the United States. New Horiz. 1994;2(3):283–290.
    1. Loss SH, Oliveira RP, Maccari JG, Savi A, Boniatti MM, Hetzel MP, et al. The reality of patients requiring prolonged mechanical ventilation: a multicenter study. Rev Bras Ter Intensiva. 2015;27(1):26–35.
    1. Cislaghi F, Condemi AM, Corona A. Predictors of prolonged mechanical ventilation in a cohort of 3,269 CABG patients. Minerva Anestesiol. 2007;73(12):615–621.
    1. Cislaghi F, Condemi AM, Corona A. Predictors of prolonged mechanical ventilation in a cohort of 5123 cardiac surgical patients. Eur J Anaesthesiol. 2009;26(5):396–403.
    1. Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical illness. Am J Respir Crit Care Med. 2010;182(4):446–454. Review.
    1. Iwashyna TJ, Hodgson CL, Pilcher D, Orford N, Santamaria JD, Bailey M, et al. Towards defining persistent critical illness and other varieties of chronic critical illness. Crit Care Resusc. 2015;17(3):215–218.
    1. Lorin S, Nierman DM. Critical illness neuromuscular abnormalities. Crit Care Clin. 2002;18(3):553–568.
    1. Mechanick JI, Brett EM. Nutrition support of the chronically critically ill patient. Crit Care Clin. 2002;18(3):597–618.
    1. Mechanick JI, Brett EM. Endocrine and metabolic issues in the management of the chronically critically ill patient. Crit Care Clin. 2002;18(3):619-41, viii.
    1. Van den Berghe G. Neuroendocrine pathobiology of chronic critical illness. Crit Care Clin. 2002;18(3):509–528.
    1. Gentile LF, Cuenca AG, Efron PA, Ang D, Bihorac A, McKinley BA, et al. Persistent inflammation and immunosuppression: a common syndrome and new horizon for surgical intensive care. J Trauma Acute Care Surg. 2012;72(6):1491–1501.
    1. Maguire JM, Carson SS. Strategies to combat chronic critical illness. Curr Opin Crit Care. 2013;19(5):480–487.
    1. McEwen BS, Wingfield JC. The concept of allostasis in biology and biomedicine. Horm Behav. 2003;43(1):2–15. Review.
    1. McEwen BS, Wingfield JC. What is in a name? Integrating homeostasis, allostasis and stress. Horm Behav. 2010;57(2):105–111.
    1. Mechanick JI, Brett EM. Nutrition and the chronically critically ill patient. Curr Opin Clin Nutr Metab Care. 2005;8(1):33–39.
    1. Iwashyna TJ, Hodgson CL, Pilcher D, Bailey M, Bellomo R. Persistent critical illness characterised by Australian and New Zealand ICU clinicians. Crit Care Resusc. 2015;17(3):153–158.
    1. Carson SS. Chronic critical illness. In: Hall JB, Schimidt GA, Wood LD, editors. Principles of critical care. New York: McGraw-Hill; 2005. pp. 207–216.
    1. Estenssoro E, Reina R, Canales HS, Saenz MG, Gonzalez FE, Aprea MM, et al. The distinct clinical profile of chronically critically ill patients: a cohort study. Crit Care. 2006;10(3):R89–R89.
    1. Carson SS, Garrett J, Hanson LC, Lanier J, Govert J, Brake MC, et al. A prognostic model for one-year mortality in patients requiring prolonged mechanical ventilation. Crit Care Med. 2008;36(7):2061–2069.
    1. Chelluri L, Im KA, Belle SH, Schulz R, Rotondi AJ, Donahoe MP, et al. Long-term mortality and quality of life after prolonged mechanical ventilation. Crit Care Med. 2004;32(1):61–69.
    1. Clark PA, Lettieri CJ. Clinical model for predicting prolonged mechanical ventilation. J Crit Care. 2013;28(5):880.e1–880.e7.
    1. Schuetz P, Müller B. The hypothalamic-pituitary-adrenal axis in critical illness. Endocrinol Metab Clin North Am. 2006;35(4):823-38, x.
    1. Kavazis AN, Talbert EE, Smuder AJ, Hudson MB, Nelson WB, Powers SK. Mechanical ventilation induces diaphragmatic mitochondrial dysfunction and increased oxidant production. Free Radic Biol Med. 2009;46(6):842–850.
    1. Bernard N, Matecki S, Py G, Lopez S, Mercier J, Capdevila X. Effects of prolonged mechanical ventilation on respiratory muscle ultrastructure and mitochondrial respiration in rabbits. Intensive Care Med. 2003;29(1):111–118.
    1. Powers SK, Kavazis AN, Levine S. Prolonged mechanical ventilation alters diaphragmatic structure and function. Crit Care Med. 2009;37(10) Suppl:S347–S353. Review.
    1. White AC. Long-term mechanical ventilation: management strategies. Respir Care. 2012;57(6):889–897. discussion 898-9.
    1. Chen S, Su CL, Wu YT, Wang LY, Wu CP, Wu HD, et al. Physical training is beneficial to functional status and survival in patients with prolonged mechanical ventilation. J Formos Med Assoc. 2011;110(9):572–579.
    1. Chen YH, Lin HL, Hsiao HF, Chou LT, Kao KC, Huang CC, et al. Effects of exercise training on pulmonary mechanics and functional status in patients with prolonged mechanical ventilation. Respir Care. 2012;57(5):727–734.
    1. Campbell GB, Happ MB. Symptom identification in the chronically critically ill. AACN Adv Crit Care. 2010;21(1):64–79.
    1. McClung JM, Van Gammeren D, Whidden MA, Falk DJ, Kavazis AN, Hudson MB, et al. Apocynin attenuates diaphragm oxidative stress and protease activation during prolonged mechanical ventilation. Crit Care Med. 2009;37(4):1373–1379.
    1. Kalb TH, Lorin S. Infection in the chronically critically ill: unique risk profile in a newly defined population. Crit Care Clin. 2002;18(3):529–552.
    1. Nelson JE. Palliative care of the chronically critically ill patient. Crit Care Clin. 2002;18(3):659–681.
    1. Nelson JE, Tandon N, Mercado AF, Camhi SL, Ely EW, Morrison RS. Brain dysfunction: another burden for the chronically critically ill. Arch Intern Med. 2006;166(18):1993–1999.
    1. Daly BJ, Douglas SL, Gordon NH, Kelley CG, O'Toole E, Montenegro H, et al. Composite outcomes of chronically critically ill patients 4 months after hospital discharge. Am J Crit Care. 2009;18(5):456–464. quiz 465.
    1. Zilberberg MD, de Wit M, Pirone JR, Shorr AF. Growth in adult prolonged acute mechanical ventilation: implications for healthcare delivery. Crit Care Med. 2008;36(5):1451–1455.
    1. Donahoe MP. Current venues of care and related costs for the chronically critically ill. Respir Care. 2012;57(6):867–886.
    1. Bigatello LM, Stelfox HT, Berra L, Schmidt U, Gettings EM. Outcome of patients undergoing prolonged mechanical ventilation after critical illness. Crit Care Med. 2007;35(11):2491–2497.
    1. Dermot Frengley J, Sansone GR, Shakya K, Kaner RJ. Prolonged mechanical ventilation in 540 seriously ill older adults: effects of increasing age on clinical outcomes and survival. J Am Geriatr Soc. 2014;62(1):1–9.
    1. Douglas SL, Daly BJ, Kelley CG, O'Toole E, Montenegro H. Chronically critically ill patients: health-related quality of life and resource use after a disease management intervention. Am J Crit Care. 2007;16(5):447–457.
    1. Durbin CG., Jr Indications for and timing of tracheostomy. Respir Care. 2005;50(4):483–487.
    1. Andriolo BN, Andriolo RB, Saconato H, Atallah AN, Valente O. Early versus late tracheostomy for critically ill patients. Cochrane Database Syst Rev. 2015;1:CD007271.
    1. Jubran A, Grant BJ, Duffner LA, Collins EG, Lanuza DM, Hoffman LA, et al. Effect of pressure support vs unassisted breathing through a tracheostomy collar on weaning duration in patients requiring prolonged mechanical ventilation: a randomized trial. JAMA. 2013;309(7):671–677.
    1. Schulman RC, Mechanick JI. Metabolic and nutrition support in the chronic critical illness syndrome. Respir Care. 2012;57(6):958–977.
    1. Fiaccadori E, Parenti E, Maggiore U. Nutritional support in acute kidney injury. J Nephrol. 2008;21(5):645–656.
    1. Thomas DC, Kreizman IJ, Melchiorre P, Ragnarsson KT. Rehabilitation of the patient with chronic critical illness. Crit Care Clin. 2002;18(3):695–715.
    1. Ambrosino N, Venturelli E, Vagheggini G, Clini E. Rehabilitation, weaning and physical therapy strategies in chronic critically ill patients. Eur Respir J. 2012;39(2):487–492.
    1. Mechanick JI, Nierman DM. Gonadal steroids in critical illness. Crit Care Clin. 2006;22(1):87-103, vii.
    1. Nierman DM, Mechanick JI. Biochemical response to treatment of bone hyper resorption in chronically critically ill patients. Chest. 2000;118:761–766.
    1. Brem H, Nierman DM, Nelson JE. Pressure ulcers in the chronically critically ill patient. Crit Care Clin. 2002;18(3):683–694.
    1. Retter A, Wyncoll D, Pearse R, Carson D, McKechnie S, Stanworth S, Allard S, Thomas D, Walsh T, British Committee for Standards in Haematology Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. Br J Haematol. 2013;160(4):445–464.
    1. Athar MK, Puri N, Gerber DR. Anemia and blood transfusions in critically ill patients. J Blood Transfus. 2012;2012:629204–629204.
    1. Carson SS. Definitions and epidemiology of the chronically critically ill. Respir Care. 2012;57(6):848–856.
    1. Cox CE, Martinu T, Sathy SJ, Clay AS, Chia J, Gray AL, et al. Expectations and outcomes of prolonged mechanical ventilation. Crit Care Med. 2009;37(11):2888–2894. quiz 2904.
    1. Hartl WH, Wolf H, Schneider CP, Küchenhoff H, Jauch KW. Acute and long-term survival in chronically critically ill surgical patients: a retrospective observational study. Crit Care. 2007;11(3):R55–R55.
    1. Carson SS, Bach PB, Brzozowski L, Leff A. Outcomes after long-term acute care. An analysis of 133 mechanically ventilated patients. Pt 1Am J Respir Crit Care Med. 1999;159(5):1568–1573.
    1. Combes A, Costa MA, Trouillet JL, Baudot J, Mokhtari M, Gibert C, et al. Morbidity, mortality, and quality-of-life outcomes of patients requiring >or=14 days of mechanical ventilation. Crit Care Med. 2003;31(5):1373–1381.
    1. Kox M, Pickkers P. "Less is more" in critically ill patients: not too intensive. JAMA Intern Med. 2013;173(14):1369–1372.
    1. Blackwood B, Alderdice F, Burns K, Cardwell C, Lavery G, O'Halloran P. Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients: Cochrane systematic review and meta-analysis. BMJ. 2011;342:c7237–c7237.

Source: PubMed

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