Long Term Outcome of ICU Survivors... How would you respond? Loo Shi Tan Tock Seng Hospital Singapore

Transcription

1 Long Term Outcome of ICU Survivors... How would you respond? Loo Shi Tan Tock Seng Hospital Singapore

2 Warning The content of this lecture may be discomforting!

3 ICU consultant receives a call from surgeon year old man In Emergency Department HR 120, BP 90/50, 38.5 o C, RR 28, GCS 11, BE -12, oliguric History of HPT, AMI 3 years ago, LVEF 45% SWMA, Med Treatment Now: Acute abdomen, CXR - gas under diaphragm. Requires laparotomy Surgeon: give him a chance! With full surgical + ICU management, what possible outcomes await him? What kind of chance?

4 PURPOSE Highlight the reality of the Long Term Outcome of critically ill patients who survived ICU Look at published data from other centres Generate thinking and discussion how would we manage this reality in our context?

5 ICU consultant receives a call from surgeon year old man In Emergency Department HR 120, BP 90/50, 38.5 o C, RR 28, GCS 11, BE -12, oliguric History of HPT, AMI 3 years ago, LVEF 45% SWMA, Med Treatment Now: Acute abdomen, CXR - gas under diaphragm. Requires laparotomy Surgeon: give him a chance! With full surgical + SICU management, what possible outcomes await him? What kind of chance are we giving him?

6 What kind of chance? Experience with similar patients in other centres

7 Geneva, Switzerland Retrosp survey Single Univ SICU >70 yr old Severe Abd Patho N=141 (100%) SAPS II: SOFA: MV 48% Press/Inotrop 27% Mech Vent 48% Surv ICU 79% ICU Death 21% Surv Hosp 67% Hosp Death 12% 2 yrs Surv 37% n=52 Indep 21% Part Dep 12% Depend 5% 2 yrs Death 30% Did Survey 26% n=36 Decline / unfit Survey 11% N=16 Issues with Daily living Assessment Of QOL - EQ-5D - SF-36 Subjective Feel on QOL Better 11% Same 8% Worse 11%

8 What kind of chance? Experience with undifferentiated patient types who survived ICU in other centres

9 Critical Care 2010, 14;R6 Journal of Critical Care (2011) 26, Critical Care 2013, 17:R100 Critical Care 2013, 17:R236

10 Critical Care 2010, 14;R6 Scotland, UK UK Prosp. Longit. cohort Single tertiary hosp Adult (med 60.5yr) Survived initial resus (not total ICU Adm)..... N= 300 (100%) APACHE II: 18 Mean ICU LOS: 6.7 Surgical: 48% Medical: 39% Surv ICU 100% Surv Hosp 97% Hosp Death 3% 6 mth Surv 60% 6 mth Death 19% Lost 21% 2.5 yr Surv 42% 2.5 yr Death 28% Lost 30% 5 yr Surv 32% 5 yr Death 33% Lost 35% Ongoing mortality QOL over 5 yr Y1: poor Y1-2.5: Improve Y2.5-5: worsen

11 How would I use all these data? A signal that such realities exists, and to ascertain the factors influencing Long Term Outcomes, eg. Injury to patient Prexisiting, acute critical illness ICU management Overall post-icu hospital care, Overall community care, philosophy and culture I need to ascertain such data in my context, as data from other centres may not be directly applicable. Use data to improve on the following: ICU management that impact Long Term Outcome Decision making process: Types: ICU admission + triage, Extent of care Decision makers: patient, surrogate, referring doctors, ICU doctors, society Influence post-icu care

12 What kind of chance? Social + Economic Impact from decreased functional status of ICU survivors

13 Critical Care 2013, 17:R100 Scotland, United Kingdom UK Prosp. Longit. cohort 22 UK Hosp ICUs > 16 yr old > 48 hr MODS Left ICU alive N= 831 (100%) APACHE II >18: 53% Surgical: 41% Medical: 59% Surv ICU 100% Surv Hosp 96% Hosp Death 4% 6 mth Surv 45% 6 mth Death 10% Lost 45% 12 mth Surv 35% 12 mth Death 11% Lost 54% Function QOL Impact on Income source Impact on Carer

14 What kind of chance? Chronic Critical Illness

15 N ENGL J MED 2014;370;2:

16 Crit Care Med 2015;43: States in USA 5 States in USA Retrosp cohort Acute care Hosp Definition of CCI ICU LOS > 8 days +one of following: - Mech Vent > 96hr - Tracheostomy - Sepsis - Severe wounds - MOF - ischaemic stroke - IC hemorrhage - TBI Incidence 7.6% Prevalence with age till 80 Outcome

17 What kind of chance? Mental + Physical Disorders after ICU Discharge

18 Current Opinion in Critical Care 2010,16: N ENGL J MED 2013;369(14): Am J Respir Crit Care Med 2012;186(4):

19 Process impacting long term outcome Acute at ICU Pat s Systems Physiological Anatomical Cognitive Psy-emotional Patho- Physiological Processes Pathologies or Injuries Management in ICU What can help? LT Outcome Good QOL Spont ADL + disabilities Assisted ADL Chronic life supp Death

20 Acta Anaesthesiol Scand 2012;56:

21 Curr Opin Crit Care 2013,19:

22 Process impacting long term outcome Acute at ICU Pat s Systems Physiological Anatomical Cognitive Psy-emotional Patho- Physiological Processes Pathologies or Injuries Management in ICU Management Post ICU LT Outcome Good QOL Spont ADL + disabilities Assisted ADL Chronic life supp Death

23 Acta Anaesthesiol Scand 2012;56:

24 Any Predisposing Factors for poor Long Term Outcome?

25 Acta Anaesthesiol Scand 2012;56:

26 Risk Factor 1: Advanced Age rit Care 2011, 15:R36 Crit Care 2011, 15:R105 J of Crit Care 2014;29:474e7

27 3 ICUs, Sweden Risk Factor 2: Previous Health State

28 Any Predisposing Factors for poor Long Term Outcome? How about Frailty?

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30 6 ICU, Alberta Canada CMAJ 2014;186(2):E95-102

31 High Risk Features Age Pre-existing: Pathology Physio Frailty others? Decision Process? Process impacting long term outcome Acute at ICU Pat s Systems Physiological Anatomical Cognitive Psy-emotional Patho- Physiological Processes Pathologies or Injuries Management in ICU Management Post ICU LT Outcome Good QOL Spont ADL + disabilities Assisted ADL Chronic life supp Death

32 Decision Process triggers a Cascade Effect Warning! Intentionally controversial from this point

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34 High Risk Features Age Pre-existing: - Pathology - Physio - Frailty -? Decision Process? Process impacting long term outcome Who decides? Acute at ICU Pat s Systems Physiological Anatomical Cognitive Psy-emotional Patho- Physiological Processes Pathologies or Injuries Management in ICU Management Post ICU LT Outcome Good QOL Spont ADL + disabilities Assisted ADL Chronic life supp Death

35 Connecticut USA >60, Cancer, CCF, COPD

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37 PLOS ONE 2014;9(5):E98246

38 Paris France Survey amongst - Patients with chronic illness. - Intensivists in France

39 High Risk Features Age Pre-existing: - Pathology - Physio - Frailty -? Decision Process? Process impacting long term outcome Who decides? Acute at ICU Pat s Systems Physiological Anatomical Cognitive Psy-emotional Patho- Physiological Processes Pathologies or Injuries Management in ICU Management Post ICU LT Outcome Good QOL Spont ADL + disabilities Assisted ADL Chronic life supp Death

40 I would like to hear your thoughts!

41 Thank You