ANWICU knowledge

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1 ANWICU knowledge This presentation is provided by ANWICU We are a collaborative association of ICUs in the North West of England. Permission to provide this presentation has been granted by the author(s). Please note that the contents of the presentations do not necessarily represent the views of ANWICU or of its membership. These resources are provided free of charge. Please let us know if you find these resources useful. You are welcome to use these resources for non-comercial presentations. We ask that you recognise and acknowledge the ANWICU knowledge group and the author(s). The slides are branded and saved as PDF files.

2 Rehab after Intensive Care Daniel Conway Consultant Anaesthesia & Critical Care Manchester Royal Infirmary

3 Challenge to post-icu Patients Psychological Physical Environment

4 Physical Problems: ICU-AW ICU Acquired Weakness Eye Problems Muscle Pain Aches/Pains Weakness Tiredness Leg Weakness Shortness of Breath Stamina (Lack) Altered Mood Fitness Sexual Disfunction Walking (Distance)

5 Leg strength needs improving short of breath, weak and have pain NMB sedatives Electrolyte / Malnutrition ICU-AW Myopathy Polyneuropathy

6 ICU Acquired Weakness ICU-AW Schwiekert, Hall Chest 2007 Incidence 2% of mechanically ventilated patients 25% mechanical ventilation> 7d (De Jonghe JAMA 02) 60 % severe SIRS, Sepsis and ARDS Risk Factors? Sedation Neuromuscular Blockade Immobility Sarcopenia

7 Critical Illness Polyneuropathy Acute axonal neuropathy Failure to wean with flaccid paralysis Typical EMG features Increases LOS/ failure to wean odds ratio= 15.4 (95% CI 4.55, 52.3) p<.001 (Garnacho-Montero et al Crit care Med 05) Complications

8 Critical Illness Polyneuropathy: electrodiagnostics

9 ICU-AW and Muscle Relaxants Puthucheary Z AJRCCM patients NDMA not associated with ICU- AW Garnacho Montero CCM 2005 RCT in ARDS 340 patients receiving cisatracurium 48hrs 90-day mortality outcomes 30.8% vs. 44.6%, p=0.04 manual muscle testing on day of Day 28, no difference in the incidence of ICU-AW 29 vs. 32%, P =0.49 Papazian ACURASYS NEJM 2010

10 Long Term Impact of ARDS Herridge NEJM year comprehensive, longitudinal data Previously healthy survivors of critical illness pulmonary, functional, and health-related quality-of-life outcomes health care utilization and costs 3, 6, 12, and 24 months and then yearly for up to 5 years after ICU discharge n=83

11 Long Term Survival after ARDS Herridge NEJM 2011

12 Long Term Impact of ARDS on mobility Herridge NEJM 2011

13 Long Term Impact of ARDS on QoL Herridge NEJM 2011

14 Long Term Impact of ARDS Herridge NEJM 2011 Persistent perceived weakness with reduced exercise tolerance on 6MWT Physical Component SF36 1SD below norm Near normal spirometry after 3 years CT changes often non-dependent pulmonary fibrosis

15 Long Term Impact of ARDS Herridge NEJM 2011 Health Costs Around CAN $ 3000/year Return to Work all bar 2 returned to work within 2 years gradual transition modified work schedule job retraining

16 Nutritional Problems post-icu ICU patients lose weight despite feed Lack of planning for nutritional requirements Post ICU Up to 20% are dysphagic aspiration risk Lack of appetite and loss of taste Physically unable to feed self Naso-gastric tubes not replaced

17 200 Poor nutrition increases LOS ICU length of stay 0 hospital los N = no yes nutrition probs post ICU

18 CPET post-icu

19 CPET post- ICU Benington, S, Eddleston J, Atkinson D. J Crit Care 2012 Ventilated 5 days 24 month period CPET performed 24 +/- 14 days post hospital discharge no adverse events seen Study Population number 50 Age 57 (31-82) Male:female 64% Days ventilated 18 (5-60) Days Critical Care 31 (8-120) Days in Hospital 38 (15-168) Values are median unless otherwise stated

20 CPET post- ICU Benington, S, Eddleston J, Atkinson D J Crit Care 2012

21 Example pre-operative v post critical illness (23days SIMV/PSV)

22 Breathless Immobility Infection Pain Weakness Mood myopathy Nutrition neuropathy Drug therapy Co-morbidities

23 Challenge to post-icu Patients Psychological Physical Environmental

24 Psychological Challenge post-icu Anxiety Depression ICU Post Traumatic Distress Cognitive Dysfunction

25 Delirium: also seen on ICU

26 ICU Syndrome / Psychosis Delirium Agitation & persecutory delusions Drug Toxicity Drug Withdrawal Sepsis and hypoxia Post-Traumatic Stress Disorder Flashbacks, nightmares, panic attacks

27 A risk factor for post-icu problems?

28 Post-Traumatic Distress NICE CG26 experience a traumatic event involving death or serious injury reaction of intense fear, helplessness and horror subsequently symptoms of intrusion, avoidance and arousal Affects 10-20% of ICU survivors (Griffiths J Int. Care Med 07)

29 PTSD and ICU survivors C Jones ICM 2007 Previous Psychological Issues Delusional Memories Sedation PTSD Restraint

30 PTSD and the Role of Diaries

31 PTSD and Patient Diaries Started in Scandinavia Belong to patient Completed by patients, relatives and staff Can include photographs Follow-up team involved in feedback

32 ICU Diaries reduce new onset PTSD following critical illness Jones Crit Care 2010 RCT 352 patients RACHEL 2 study Exclude pre-existing PTSD, withdrawals & Everybody enrolled had a diary Post-Traumatic Stress Syndrome 14 screen at 1 month and 3 months Randomised at 1 month to receive diary or wait until 3 months to receive diary

33 ICU Diaries reduce new onset PTSD following critical illness Jones Crit Care 2010 New-onset PTSD at 3 months: 8 of 162 (5%) with diary 21 of 160 (13.1%) no diary patients receiving diary at one-month read it a median of three times

34 Challenge to post-icu Patients Psychological Physical Environmental

35 Why post-icu ward care is difficult Vulnerable heterogeneous group Patients have need for information Families know more about events than staff Fear factor / lack of trust Mortality = 10% Includes ICU re-admission, LOTA, HDU Unpredictable ward mortality = 5%

36 Role of Intensive Care Follow Up Team Nurse/Dr Run Out Patient Clinic Concerns regarding gaps in care following critical care discharge Post-ICU hospital mortality 8-12% Development of MDT to assist ward teams in caring for ICU survivors

37 Post ICU Rehab NICE CG83 Patient Centred Rehab to start on ICU ICU team should follow up patients : On Ward In Community

38 Pathway for Post-ICU on Ward MAJOR REHAB NEEDS Individualised Pathway Physical rehabilitation programme designed and delivered by Follow Up Physio. Non-physical components referred as appropriate to other clinicians MINOR REHAB NEEDS Predictable Pathway Physical rehabilitation programmes delivered by Divisional physiotherapists. Non-physical components referred as appropriate to other clinicians

39 Improving Quality of Life post-icu Jones Skirrow Griffiths Humphris Ingleby Eddleston Waldmann Crit Care Med 2003 Randomised control trial of rehabilitation 6-week self-help rehabilitation manual v clinic appointments and telephone support 93 page manual Self-directed exercise programme Patient diary Improved physical function (SF36)

40 Post- ICU gym based rehab Similar to Cardiac or pulmonary rehab 6 to 8 week course Run by AHP s Includes lifestyle advice Group support

41 ICU Rehab RCT Underway at CMFT 90 patients recruited CPET + SF-36 at baseline Randomised to Class v Rehab manual for 8 weeks Results in Press

42 Improving Outcomes Post-ICU Minimise Harms Early Rehab on ICU Gym based rehab Patient Diaries

43 Thanks for listening...any questions?

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