Critical illness- A new co-morbidity?

Transcription

1 Critical illness- A new co-morbidity? Brian H Cuthbertson Chief, Department of Critical Care Medicine Sunnybrook Health Sciences Centre Professor of Anaesthesia University of Toronto Toronto, Canada

2 Critical illness- What doesn t kill you makes you weaker Brian H Cuthbertson Chief, Department of Critical Care Medicine Sunnybrook Health Sciences Centre Professor of Anaesthesia University of Toronto Toronto, Canada Detsky

3 Trying to answer the question- Weren t they like this before they came into ICU?

4 Trying to answer the question- Isn t it all just (accelerated) old age

5 Trying to answer the question- Isn t it just being in hospital that s bad for you

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8 Is critical illness a co-morbidity? Effects on survival

9 Survival Survival after critical illness General population Series1 Series ICU survivors Years after ICU admission Wright et al

10 Survival Survival after critical illness General population ICU survivors Years after ICU discharge Series1 Series2 Williams et al

11 Survival Survival after critical illness General population ICU survivors Years after ICU admission Series1 Series2 Cuthbertson et al

12 Risk of death after critical illness Williams et al

13 Weren t they like this before they came into ICU?

14 Trajectory of mortality around critical illness Pre-ICU period ICU and 5 yr follow-up Long-term Mortality gap ICU patient control

15 Trajectory of mortality around critical illness Onset of critical illness You are Here! ICU patient control

16 Survival Is it the diagnosis that determines 100 mortality? Years after ICU admission Population Trauma ARDS General ICU Sepsis

17 Is it the severity of illness that drives mortality? Loan 2012

18 Isn t it just all (accelerated) old age?

19 Survival Is it age that drives mortality? Years after ICU admission Population- 60 s 40 s 40 s 60 s 50 s

20 Age Co-morbidity Predictors of long term mortality Primary diagnosis Pre-morbid quality of life Organ failure Severity of illness

21 Age Co-morbidity Predictors of long term mortality Primary diagnosis Severity of illness

22 Is critical illness a co-morbidity? Quality of life

23 Physical QOL Physical quality of life Starts low Rebounds Again deteriorates Gets worse PreICU 3mths 6mths 1yr 2.5yrs 5yrs Years after ICU admission 1.5 SD below pop Cuthbertson 2009

24 Physical QOL Physical quality of life after ARDS SD below popn SD below popn 20 3mths 1yr 2yr 3yrs 4yrs 5yrs Years after ICU admission Herridge 2011

25 Weren t they like this before they came into ICU?

26 Trajectory of QOL around critical illness Morbidity gap Morbidity gap yrs before Pre-ICU 5yrs after

27 Trajectory of QOL around critical illness yrs before Pre-ICU 5yrs after

28 Trajectory of QOL around critical illness yrs before Pre-ICU 5yrs after

29 6MW percentage of normal But look at these exercise tolerances mths 1yr 2yr 3yrs 4yrs 5yrs Years after ICU admission Herridge 2011

30 Body weight Loss of muscle mass and physical quality of life months 6 months 9 months 12 months Months after ICU admission Herridge 2011

31 Isn t it just being in hospital that s bad for you

32 Effect of aetiology of critical illness on quality of life Sepsis Trauma ARDS 30 General SD below pop mths 6mths 1yr 2.5yrs 5yrs Years after ICU admission

33 Is there an exposure relationship? 50 Surgery Critical illness Premorbid 1 mth 3mths 6mths 1yr 2.5yrs 5yrs

34 Isn t it just all (accelerated) old age?

35 Affect of age on QOL s 40 s 40 s 60 s mths 6mths 1yr 2.5yrs 5yrs Years after ICU admission

36 Herridge et al 2011 Effect of age on QOL

37 Physical QOL Effect of age on QOL Younger Older Age related deterioration Premorbid 3mths 6mths 1yr 2.5yrs 5yrs Years after ICU admission Cuthbertson 2009

38 Weren t they like this before they came into ICU?

39 Functional trajectories before and after sepsis Iwashyna 2010

40 What are ADL deficits? Iwashyna 2010

41 Cognitive problems after sepsis Iwashyna 2010

42 Trajectories for delirium after sepsis Dead Moderate/ Severe Moderate/ Severe Minor Minor None None Before sepsis After sepsis

43 Trajectories for delirium after sepsis Dead Moderate/ Severe Moderate/ Severe Minor Minor None None Before sepsis After sepsis

44 Age Co-morbidity Predictors of poor physical QOL ICU length of stay Pre-morbid quality of life Organ failure Severity of illness

45 Neuropsychological trauma Fear of death Failure to identify Poor physical QOL Psychological morbidity Previous psychiatric history Family consequences Societal consequences

46 What do these outcomes actually mean to our patients?

47 Domains of Quality of life Physical quality of life Geriatric conditions Activities of daily living What s this bit called?

48 Domains of quality of life Physical quality of life Geriatric conditions Activities of daily living Or this bit?

49 Domains of quality of life Physical quality of life Activities of daily living Geriatric conditions Or even this bit?

50 Why does this all happen?

51 Function (organ or holistic) Function ICU admission Failure Time Death

52 Can we conceptualise this?

53 Physical and mental / cognitive baseline status (Modified) Iwashyna conceptual model Acute illness Organ function impairment Activity and functional limitation Participation restrictions and disability Quality of life

54 The destructive Physical QOL Previous acute illness Tissue pathology cycle Participation restriction Limitation Limitation Participation restriction Tissue pathology Index acute illness Physical QOL

55 The Limitation Limitation Tissue pathology Physical QOL Tissue pathology Tissue pathology Physical QOL Limitation Acute illness Acute illness Acute illness downward Physical QOL spiral Death

56 Conclusions Critical illness is associated with excess morbidity and mortality Some of this is due to underlying morbidity The interactions between underlying chronic and acute morbidity is complex We must be realisitic about what we can achieve when rehabilitating these patients

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