A session blog from Day 2 of State of the Art, London December 2015. See the full list.
Blogger PHW (@drph_w)
Chronic critical illness: Prevalent and under-recognised?
- Multiple evidence of those with prolonged critical illness have poor long term prognosis.
- Are we converting dead patients into the nearly dead?
- People with dementia more likely to get pneumonia which then accelerates your dementia.
- Surviving sepsis often followed by prolonged tail which changes the course of subsequent chronic illness.
- Shattuck lecture http://www.nejm.org/doi/full/10.1056/NEJM199711063371906
- Damuth et al http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(15)00150-2/abstract
Chronic critical illness: worse than malignancy?
- There is a syndrome of chronic critical illness with chronic co-morbidities overlapping with acute critical illness leading to chronic critical illness
- This is a big problem in the USA costing $36billion>
- We are creating a non-darwinian physiological state
- Non mortal outcomes lead to patient suffering, brain dysfunction, total dependence and family burden and distress
- We need to think about when to stop the train on these patients and frequently consider their future prognosis
- http://www.ncbi.nlm.nih.gov/pubmed/10315661 original paper on chronically critically ill
- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4385299/ web based decision aid for families
Genomics and metabolomics: which patients get worse?
- Functional independence measure very useful tool range 18-126
- FIM < 40 total dependence
- Very limited improvement after 6 months confounding factors including less rehab after discharge
- 7 day FIM is associated with age and ICU LOS
- if <42 years ventilated less the 2 wks FIM 107 (able to self care)
- If >66 ventilated over 2 weeks FIM 44 (highly dependent)
The UK landscape: epidemiology and research
- Patchy data
- No ICNARC analysis to date
- We don’t know the size of the problem
- Pilot looked at 1 tertiary centre 1 medium size DGH and 1 small DGH
- 9000 admissions 16% Chronic critical illness compared with 8 % in USA
- 31% of bed days occupied by these 16% of patients
- 50% of bed days taken up in DGH
- This is a big problem with implications for resource utilisation
- Pick your fights wisely to improve outcome!
Should we be more brutally honest with our patients?
JN we need to talk to patients more about outcomes and open the dialogue
Don’t be brutal as less is heard.
DA we should encourage discussion about realistic trajectory and help patients create meaningful advanced directives.