DIAGRAM OF THE PRESENTATION. Post ICU Rehabilitation. Effective strategies in ICU. During two last decades

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1 1st European Conference on Weaning & Rehabilitation in Critically ill Patients INTERNATIONAL EARLY MOBILISATION NETWORK Post ICU Rehabilitation Serafeim N.

gr DIAGRAM OF THE PRESENTATION Recent strategies in ICU increase effectiveness Post ICU Disability Syndrome Heterogeneity of ICU Survivors Post ICU Rehabilitation RCTs Need for Multidisciplinary

1 1 1st European Conference on Weaning & Rehabilitation in Critically ill Patients INTERNATIONAL EARLY MOBILISATION NETWORK Post ICU Rehabilitation Serafeim N. Nanas Professor of Critical Care Medicine Evaggelismos Hosp., Medical School National & Kapodestrian University of Athens DIAGRAM OF THE PRESENTATION Recent strategies in ICU increase effectiveness Post ICU Disability Syndrome Heterogeneity of ICU Survivors Post ICU Rehabilitation RCTs Need for Multidisciplinary Approach Challenges - Prospective Synopsis During two last decades Effective strategies in ICU 3 Improved ICU Medical Care increased survivors after severe disease Morbitity Mortality ICU & Hospital stay 4 Better instrumentation (Ventilators, CRRT) Protective ventilation Early goal directed therapy Less Sedation Early Mobilization & Rehabilitation END POINT 28 or 90 days outcome: ICU or Hospital mortality Limited Long Term Data, post icu rehab nov 2013 Ser Nanas 1

5 ICU SURVIVORS I The Magnitude of the problem Multiorgan dysfuction Pulmonary Renal impairement Neurocongnitive Physical ICUa Weakness 25%- 60% Polyneuromyopathy Dysphagia Heterotypic Ossification 6

Family dysfunction Griffiths JA et al. Anaesthesia 2006;61(10):950-5 Herridge MS et al. N Engl J M.2003;348(8):683-93 Michaels AJ et al. J Trauma.1999;47(3):460-7 Stoll C et al.

2 5 ICU SURVIVORS I The Magnitude of the problem Multiorgan dysfuction Pulmonary Renal impairement Neurocongnitive Physical ICUa Weakness 25%- 60% Polyneuromyopathy Dysphagia Heterotypic Ossification 6 ICU SURVIVORS II The Magnitude of the problem Delirium, cognitive disorders Lethargy Depression % Anxiety 23-48% PTSD (Post traumatic stress disorder) 20-55% Health Related Quality of Life Family dysfunction Griffiths JA et al. Anaesthesia 2006;61(10):950-5 Herridge MS et al. N Engl J M.2003;348(8): Michaels AJ et al. J Trauma.1999;47(3):460-7 Stoll C et al. J Thorac Cardiovasc Surg 2000;120(3): Davidson JR et al. Psychol Med 1997;27(1): Deja M et al. Crit Care. 2006;10(5):R147 Papathanassoglou ED et al. Nurs Crit Care 2010;15(3): Dysphagia, a Common disorder Videofluoroscopic Swallow Evaluation In patient without brain injury Is very prevalent in patients with ICUa Weakness (10 fold increase risk for aspiration) Aspiration Pneumonia morbidity & mortality Mirzakhani H. et al Anesthesiology 2013; 119: In our step down Unit 30% Dysphagia (48/165) Malandraki G et al, 2012 # of patients Severity of dysphagia Normal Mild Moderate Severe Malandraki G et al, Γεωργία Α. Μαλανδράκη, Ph.D., CCC-SLP post icu rehab nov 2013 Ser Nanas 2

3 9 Neurocognitive Dysfunction Undetected Only in memory Persist - 70% at discharge - 47% at 2yrs - up to 6yrs post-discharge Rothenhausler HB et al. Gen Hosp Psychiatry 2001;23(2): % at 6 months postdischarge Jackson J et al. Crit Care Med 2003;31(4): Delirium is related to *Neurocognitive Dysfunction *Hypoxemia Hopkins RO et al. Am J Respir Crit Care Med 1999;160(1):50-6 *Sepsis & Cytokine mediation Reichenberg A et al. Arch Gen Psychiatry 2001;58(5): Long Term Cognitive impairment after ICU Multicenter study Pandharipande et al., 2013, NEJM, 369, Medical/surgical ICUs Respiratory failure, Cardiogenic or Septic Shock 821 pts enrolled IQCODE, CDR cognitive baseline: 6% Delirium during hospital stay: 74% Global cogni7on scores in ICU 3 months: months: 80 (71-87) normal mild cogni@ve impairment moderate trauma@c brain injury Alzheimer s disease 12 Prevention of Neurocognitive Dysfunction A. Awakening B. Breathing trials C. Choice of sedation and analgesia D. Daily delirium monitoring E. Early 3 12 months scores of moderate trauma@c brain injury 40% 34% scores of mild Alzheimer s disease 26% 24% delirium dura@on was associated to cogni@on scores *3 times more likely to return to independent functioning Morandi A et al. Curr Opin Crit Care 2011;17(1):43-9 Schweickert WD et al. Lancet 2009;373(9678): Pandharipande et al., 2013, NEJM, 369, post icu rehab nov 2013 Ser Nanas 3

4 13 Complication in family members of ICU survivors Anxiety Depression PTSD (40%) up to 6months later HADS (Hospital Anxiety and Depression Scale) IES (Impact of Events Scale) Horowitz M et al. Psychosom Med 1979;41(3): Jones C et al. Intensive Care Med 2004;30(3): Rehabilitation after Critical illness Jones Chr et al, Crit Care Med 2003: 31: RCT, 6 months, 126 ICU survivors Intervention: 6 weeks self help rehabilitation manual SF-36, HAD End points: Physical Function, Depression, PTSD 8 weeks, 6 months 15 A self-help rehabilitation manual is effective in aiding Physical recovery and Reduction depression 16 Post Traumatic Stress Disorder Jones C et al. Crit Care 2010;14(5):R168 Multicentre 160 int 162 standard care Intervention : Diary vs Standard care 8% less PTSD PTSD 21 (13.1%) vs 8 (5%) 0.02* post icu rehab nov 2013 Ser Nanas 4

5 17 Post Traumatic Stress Disorder Jones C et al. Crit Care 2010;14(5):R Home-based Physical Rehabilitation D. Elliot et al, Crit Care 2006, 10:R90, & Crit Care 2011:15:R142 Multicenter RCT, 200 ICU survivors, self care, (gastr, 30% resp. 24%, CV 20%, Sepsis 8%, Tr 6%) Interv: 8 weeks Home Based Rehab Programme, HRQoL SF-36, 6 MWT, DASS-21, IES No significant difference :Physical & Functional Small number, placebo effect, compliance?? Close to normal?? Heterogenous group!! enrolment of patients with functional weakness or impairement Exercise Rehabilitation of ICU survivors Linda Denehy et al Crit Care 2013, 17:R156, 19 RCT, 150 ICU survivors, Intervention: Exercise in ICU, the Ward, and 8 weeks as outpatients TUG, 6 MWT, Physical Function, SF-36, AQoL 12 months Follow up : No Difference Exercise Rehabilitation of ICU survivors Linda Denehy et al Crit Care 2013, 17:R156, months Follow up : No Difference Increased 6MWT change over time on intervention group post icu rehab nov 2013 Ser Nanas 5

21 PRaCTICAL study Cuthbertson BH, BMJ 2009;339-b:3723 RCT, multicentre 286 icu

programme vs standard care SF-36, HADS, Cost effectiveness, HCQoL No difference

(protocol) 22 RCT, Usual Care, Early mobility / Physical Rehabilitation

Function Functional Mobility Global Cognitive Function TeleRehabilitation Tele

6 21 PRaCTICAL study Cuthbertson BH, BMJ 2009;339-b:3723 RCT, multicentre 286 icu survivors, 12 months 3 UK hospitals Nurse led intensive care follow-up programme vs standard care SF-36, HADS, Cost effectiveness, HCQoL No difference Early Cognitive & Physical Rehab ACT-ICU Brummel NF et al Phys Ther 2012; 92 (protocol) 22 RCT, Usual Care, Early mobility / Physical Rehabilitation Cognitive & Physical rehabitation 3 & 12 month follow up assessment Executive Function Functional Mobility Global Cognitive Function TeleRehabilitation Tele Rehabilitaion Post ICU Rehabilitation using telemedicine services A feasibility study Why Telerehab? Home the best environment Utilization of current technology Improvement of compliance Patient at home Internet Hospital post icu rehab nov 2013 Ser Nanas 6

Systemic effect NeuroMuscular Electrical Stimulation in ICU Patients and ICU Survivors Oxygen consumption rate and endothelial function (reperfusion rate) measured by NIRS Gerovasili et al Chest.

2009 26 On going studies The Role of NeuroMuscular Electrical Stimulation (NMES) for Post ICU Rehabilitation, Intervention: NMES, Sham Telerehabilitation for ICU Survivors (feasibility st) Exercise

Cognitive and physical rehabilitation of intensive care unit survivors: Results of the RETURN randomized controlled pilot investigation J.

strength exercises) and functional rehabilitation VS usual care Primary outcomes: TOWER and TUG test A multicomponent rehabilitation program for ICU survivors combining cognitive, physical, and

7 Systemic effect NeuroMuscular Electrical Stimulation in ICU Patients and ICU Survivors Oxygen consumption rate and endothelial function (reperfusion rate) measured by NIRS Gerovasili et al Chest Preserves muscle mass (a) Absolute difference (cm) and (b) relative difference (%) in cross section diameter (CSD)*significant between-group difference (P < 0.05). Gerovasili et al Critical Care On going studies The Role of NeuroMuscular Electrical Stimulation (NMES) for Post ICU Rehabilitation, Intervention: NMES, Sham Telerehabilitation for ICU Survivors (feasibility st) Exercise after Intensive Care Unit: a Randomised Controlled Trial ( REVIVE) Intervention : exercise Program Recovery of Post Icu Care Patients RAPIT Study Intervention: Standardized Follow Up programs Cognitive and physical rehabilitation of intensive care unit survivors: Results of the RETURN randomized controlled pilot investigation J. Jackson, et al Crit Care Med 2012;40(4):1-10 Feasibility Study (8 intervention 9 control) Intervention: 6 in person visits for cognitive rehabilitation+ 6 televisits for physical (endurance and strength exercises) and functional rehabilitation VS usual care Primary outcomes: TOWER and TUG test A multicomponent rehabilitation program for ICU survivors combining cognitive, physical, and functional training appears feasible and possibly effective in improving cognitive performance and functional outcomes in just 3 months. A MULTIDISCIPLINARY TEAM 28 Speech specialist Social worker Respiratory therapist Physician Family ICU SURVIVORS Physical therapist Nurse Psychiatrist post icu rehab nov 2013 Ser Nanas 7

8 29 Doctor Nurse Psychiatrists ICU Follow-up Clinic Respiratory Therapists Physical Therapists Social Workers Speech Specialist ICU, Step Down Unit Ward, Rehab Center, Outpatient follow up Goals of Care Spiritual needs Psychological concerns Physician-patientfamily communication Crocker C. Br J Nurs 2003;12(15): Griffiths J et al. Intensive Care Med 2006;32(3): Limitation of Post ICU Rehabilitation 1. Lack of evidence RCTs with small numbers 2. Specific groups isolated modalities 3. Cost effectiveness has not been shown 4. In Clinical practice The lack of continuous after ICU discharge SYNOPSIS I ICU Survivors a population with high Morbitity, Heterogeneity and broad spectrum of symptoms NMES seems to be effective as prevention as well as for therapy of ICU acquired Weakness. It is well tolerated and easy to applied It may be incorporated in holistic approach Dysphagia is a overlook common problem The post ICU Studies up to Now included small number of patients, with specific morbidity, and isolated modality of intervention SYNOPSIS II ICU Follow up Clinic with a Multidisciplinary Team, Patient and Family may be effective, It has to be tested. More studies are needed to rehabilitation models suitable for individual patient for long term functional and neuropsychological impairment Co-ordinated, multiprofesional rehabilitation program begins at the admission in ICU, and continue in step down Unit, Ward, Rehabilitation center and community Individualized for each patient post icu rehab nov 2013 Ser Nanas 8

9 Thank you for your attention!! post icu rehab nov 2013 Ser Nanas 9

Rehabilitation after Critical Illness: What Should this Look Like?

Rehabilitation after Critical Illness: What Should this Look Like? Margaret Herridge MD MPH Associate Professor of Medicine Interdepartmental Division of Critical Care University of Toronto Canadian Critical