A session blog from Day 2 of State of the Art, London December 2015. See the full list.
Blogger Ben Attwood (@bhca)
The patient experience (video)
- Video of a patient, ‘Bob’.
- Honest reflection of experience in critical care. Music was a solace, especially at night when difficult to sleep
- Warmth of nurses
- Cried a lot
- Goals – 3 steps to a chair, walking across a room, first set of stairs. Structure helpful
- Family and Friends
- Physio, hydrotherapy, reading (especially Jamie Andrews’, “ Life and Limb”)
- Feels 60% recovery @2 years. Electric bike real bonus
- criticalcarerecovery.com – support resource for patients in recovery.
Pro-Con: Can we make a difference? (Yes)
Definitions of recovery (revival/healing, reclamation) and rehabilitation (reintegration).
“…quality means care that is personal to each individual” – Darzi
Cancer and stroke patients have clear pathways – what about patient leaving ICU?
Stressful times around discharge from ICU and hospital.
RECOVER RCT – JAMA Int medicine – improving quality during early post ICU therapy
Post intensive Care Syndrome – poor psychological and physical recovery post ICU.
Looks at Re-admission to acute hospital – 23% re-admitted within 3 months as emergency, 50% readmitted within 1 year.
Why might rehabilitation be ineffective?
Patient may not be able to comply.
Acute factors ‘block’ recovery process – muscle lesion
CRP >10mg/L associated with higher risk of poor recovery
Social deprivation and co-morbidities
To finish, defining ‘treatment’ and ‘care’ – patients need individualised therapy through case management, not ‘tick box’ care.
- Patients suffer excess mortality after ICU
- More to quality than just therapy
- Personal support important to patients
- Education and information vital
- Patients need individualised therapy through case management, not ‘tick box’ care.
Pro-Con: Can we make a difference? (No)
Eddy says he has no conflicts of interests, although he also says it’s challenging for him to argue against something he believes works!
First – Is it safe/feasible? Bailey et al 2007 Crit Care Med suggests early activity is feasible and safe in respiratory failure patients.
Will everyone benefit? There are some clinical phenotypes and molecular mechanisms that may not be modifiable, or have rehab potential.
Can we predict who is at highest risk of developing ICU acquired weakness? Some recent studies suggest Yes.
What is the optimal timing? PRaCTICaL and ReCOVER trials look at this.
Bed rest single risk factor most consistently associated with muscle weakness throughout longitudinal follow-up. Uses ‘Cliff effect’ to illustrate importance of upstream intervention being more useful to than downstream.
AVERT study = RCT for early mobilisation (within 24 hours of ICU admission)
Burdens of survivorship.
- Avoid prolonged enforced bed rest/immobility
- Target lighter levels of sedation (or none!)
- Prevent development of delirium
- Avoid potential of neuro/myotrauma
- Consider early rehabilitation where possible
When do you start rehab in your ICU?
– ‘Not early as I’d like”,
- ‘within 48hrs’ (though this is rarely achieved)
- ‘PT planned from when the patient is admitted’
- Try to sit patient up and get to end of bed asap
What sedation approach do you use?
– analgesia first.
– Could do better!
– Improved since targetting RASS.
Pre-existing chronic conditions? Do they not respond or do we need to use different outcome measures?
– TW – having thought about this a lot – probably need different expectations with this cohort. More expertise in chronic disease management required.