CNE: Beyond discharge: Impairment after critical illness
Through assessment and education, we can help ensure that the long-term effects of critical illness are recognized, addressed, and perhaps averted.
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After reading the article you should be able to:
1. Discuss the demographics of critical illness survivors.
2. Describe the physical long-term effects of critical illness.
3. Describe the emotional long-term effects of critical illness.
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By NANCY GRUBER, RN, BSN, CCRN
NANCY GRUBER is a senior staff nurse in the Weinberg Intensive Care Unit at The Johns Hopkins Hospital in Baltimore. She has no financial relationships to disclose. EDITOR: KATHLEEN A. MOORE, RN, BS.
Through assessment and education, we can help ensure that the long-term effects of critical illness are recognized, addressed, and perhaps averted.
Approximately 4 million people are admitted to ICUs in the United States each year. Of these, some 5 – 10% stay for weeks or months, using about a quarter of the hospital's budget.1
Historically, the care of critically ill patients focused on the primary outcome: survival to hospital discharge. Today, however, our expectations are broader. Research is looking beyond hospitalization and discharge at the long-term outcomes of critical illness: the problems patients face months to years after their ICU stay. Unfortunately, little of the information gleaned from this research is shared with those who need it most: critical-illness survivors and their families.
In preparation for discharge and the resumption of "normal" life, patients and their loved ones need to know how the ICU experience could affect them six months, one year, even six years down the road. Nurses, therefore, must be familiar with research on the long-term effects of critical illness—polyneuropathy, cognitive impairment, emotional problems, and diminished quality of life—so that we can better equip patients and families to recognize and manage these potential sequelae.
The effects of critical illness polyneuropathy
Several factors place critical care patients at risk for the sensorimotor impairment known as critical illness polyneuropathy. Three of the biggest factors are mechanical ventilation, multiple organ dysfunction syndrome (MODS), and sepsis. Critical illness polyneuropathy occurs in 47% of patients who are mechanically ventilated for more than seven days, and 73% of patients with MODS and sepsis.2 Other possible contributors to the development of polyneuropathy in ICU patients are trauma, systemic inflammatory response syndrome, adult respiratory distress syndrome (ARDS), and treatment with commonly used ICU drugs such as corticosteroids, sedatives, neuromuscular blockers, and aminoglycoside antibiotics.
Patients with critical illness polyneuropathy have symmetric motor, sensory, or sensorimotor impairment which may include: acute muscle weakness, typically affecting the distal extremities first; reduced deep tendon reflexes; paresthesia; global muscle weakness; and difficulty being weaned from the ventilator. The condition affects skeletal muscle tone and posture, which are controlled in part by the myotatic reflex (also known as the deep tendon or stretch reflex). This reflex causes tonic contraction of the muscle in response to stretching. Prolonged immobility, which many ICU patients experience, decreases the activity of this reflex. Without stimulation, muscles lose their ability to generate force.
Immobility leads to muscle wasting. A patient in the ICU for acute critical illness loses approximately one pound of body weight for each day that he's ill. Someone in the ICU for a prolonged period will lose, on average, 18 – 20% of his body weight.3 When loss of muscle mass occurs, patients have a hard time handling changes in electrolyte balance, and are unable to maintain homeostasis over long periods of time. Prolonged immobility and critical illness polyneuropathy also put patients at risk for osteoporosis and contracture.
Impairment associated with critical illness polyneuropathy, including weakness and fatigue, can persist for up to a year after onset. Such impairment restricts the patient's physical function, including his mobility; undermines his autonomy; and may limit his ability to participate in work, leisure, and social activities.
The emotional consequences of critical care
Hospitalization can wreak havoc on psychological well-being, and a stay in the ICU—with its social isolation, tense atmosphere, and sleep deprivation—can be especially traumatic. The lack of privacy in the critical care unit, loss of control over the environment, and fear are common contributors to patients' stress levels. After leaving the ICU, patients may experience psychological or emotional effects, including depression, anxiety or tension, loss of control and self-esteem, loneliness, isolation, amnesia, persistent and vivid dreams, hallucinations, or delusions. A lengthy stay in ICU can even lead to post-traumatic stress disorder (PTSD), where patients present with symptoms similar to those experienced by war veterans (including flashbacks, nightmares, and hallucinations). The incidence of PTSD after being in critical care units can be as much as 25 – 45%,4 but is higher in critical care survivors who were sedated for a long period of time and those who suffered from ARDS.5
Negative emotions associated with an ICU stay may persist for months to years after hospitalization. Critical care survivors are able to remember ICU-related events and dreams in detail, months after discharge. When asked to recall their ICU experience, survivors have reported a mixture of factual events and dreams. Those who in recollection perceived the events of their ICU stay as a dream had been mechanically ventilated, in ICU longer, and sicker than those who did not. These patients were also more likely to have related dreams after leaving the ICU.6 Dreams frequently involved themes of body distortion and altered sensation.6
Cognitive impairment poses challenges
Critical illness can lead to significant impairment of neurocognitive function, which can last for up to six years7 following ICU discharge. Neurocognitive impairment can affect the person's work productivity—even worse, his ability to return to work at all—and this may result in substantial economic hardship. Even mild cognitive deficits can lead to serious economic consequences. What's more, many critical illness survivors require some form of caregiver support, which may further increase the economic burden. All of this affects the individual's lifestyle and functioning, reducing both quality of life and life satisfaction.
Although patients may apply for disability, they usually are only eligible after a prolonged time out of work, secondary to a long illness. You can facilitate this process through referrals to social services staff at the hospital, who can help patients obtain the necessary home care after discharge.
Critical-illness survivors often experience problem solving difficulty and poor memory, either of which may be significant and may persist for more than two months7 after ICU discharge. Former ICU patients have reported slow mental processing, difficulty remembering appointments, impaired visual and spatial ability, impulsivity, learning problems, difficulty concentrating, shortened attention span, and decreased reaction time. Global loss of cognitive function is also possible. Some survivors of critical illness develop what's called "dysexecutive syndrome," which is characterized by problems with memory, problem solving, and social decision making.8
Research on former ARDS patients is contributing to our understanding of the neurocognitive consequences of critical illness. One study found evidence of significant cognitive impairment and functional disability in ARDS survivors up to a year after ICU admission.8 In another, researchers found that 80% of ARDS survivors had decreased or impaired memory, attention, concentration, or processing speed a year after hospital discharge.9 Studies of other critical-illness survivors—long-term medical ICU patients, coronary artery bypass graft recipients, and patients who'd undergone mechanical ventilation for prolonged periods—have shown that cognitive impairment can persist for six to 12 months following hospitalization.8,10,11
Researchers don't fully understand the mechanisms responsible for the neurocognitive consequences of critical illness. What they do know is that the problem is multifactorial. In survivors of ARDS, the hypoxemia that occurred during the acute illness appears to be a contributing mechanism.12 In addition, ICU survivors who have had cardiopulmonary bypass procedures may be at greater risk for cognitive impairment.
Another contributing factor is delirium. In ICU patients, delirium is not uncommon; it has many causes, including medication, metabolic imbalances, hypoxia, hypotension, blood loss, hemodynamic instability, sepsis, ischemia, and inflammation. Any of these factors increases a patient's risk for delir-ium and, in turn, long-term neurocognitive impairment.
ICU survival and quality of life
The long-term effects of critical illness can significantly affect quality of life. While the patient may be happy to be alive and home, he may have unrealistic expectations regarding how quickly he'll recover, and may feel frustrated that he's not yet "back to normal."
Some organ systems need more time than others to recover after critical illness, some taking more than a year to reach their final functional status.13 Sepsis survivors often have residual organ dysfunction, which can cause persistent problems such as dyspnea, fatigue, depression, and impaired physical functioning.14 Survivors of ARDS may have functional limitations even a year after their ICU discharge.3
Clinicians who work with critically ill patients can take measures to reduce the likelihood that serious long-term impairments will develop, worsen, or go undetected. Here are some suggestions:
Perform in-depth neurological exams. Use a mini-mental state examination that tests for orientation, registration, attention and calculation, recall, and language. A nurse-friendly tool can be found at www.chcr.brown.edu/MMSE.pdf. Also, evaluate deep tendon reflexes and assess for loss of muscle strength and tone. Document and track any perceived weakness. Initiate physical rehabilitation early on to reduce the likelihood of residual deficits and long-term disability. Monitor weight loss, sleep level, and sedation effect, and maintain electrolyte and acid-base balance.
Lower lights and minimize noise and other unnecessary disturbances to reduce sleep deprivation. As best as possible, maintain a calm environment and allow the patient ample time for uninterrupted sleep.
Assess for delirium in long-term ICU patients as well. To reduce stress and delirium, consider implementing complementary and alternative therapies, such as massage or aromatherapy, and encourage family visitation to ease anxiety.
Develop a teaching plan to prepare critical care patients for what to expect during their stay and once they've returned home. When indicated, discuss such topics as residual weakness, weight loss, fatigue, dreams, fragmented memories, amnesia, PTSD, employment issues, and quality of life. Instruct family and patients to watch for symptoms of dementia, delirium, and medication withdrawal, and arrange for physical or cognitive rehabilitation, mental health counseling, and other services as needed.
Caution patients not to feel frustrated if they don't return to their pre-admission state of health right away. Tell them they may have negative emotions associated with their ICU stay for months—perhaps years—after they return home. Reassure them that these reactions are an expected part of the recovery process, and that help is available, even if the need for further counseling may not be identified immediately after discharge. Once it is recognized, various insurance policies can cover these costs, reducing barriers to care.
Saving lives is obviously our job, but so is preserving quality of life. We can do that by including both short- and long-term outcomes in our planning and education. Teach patients that physical exercise, mental exercise (reading, puzzles, math), and diet are all elements of rehabilitation and recovery and must be part of the care plan. The more the critical-illness survivor and his loved ones know, the better equipped they'll be to handle the transition from hospital to home, and the long road that awaits them.
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3. Herridge, M. S., Cheung, A. M., et al. (2003). One-year outcomes in survivors of acute respiratory distress syndrome. N Engl J Med, 348(8), 683.
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5. Kapfhammer, H. P., Rothenhausler, H. B., et al. (2004). Posttraumatic stress disorder and health-related quality of life in long-term survivors of acute respiratory distress syndrome. Am J Psychiatry, 161(1), 45.
6. Roberts, B. L., Rickard, C. M, et al. (2006). Patients' dreams in ICU: Recall at two years post discharge and comparison to delirium status during ICU admission. Intensive and Crit Care Nurs, 22(5), 264.
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8. Jones, C., Griffiths, R. D., et al. (2006). Significant cognitive dysfunction in non-delirious patients identified during and persisting following critical illness. Intensive Care Med, 32(6), 923.
9. Jackson, J. C., Hart, R. P., et al. (2003). Six-month neuropsychological outcome of medical intensive care unit patients. Crit Care Med, 31(4), 1226.
10. Vibha, D., Kalita, D., et al. (2006). Coronary artery bypass surgery: Does it lead to cognitive impairment? Annals of Indian Academy of Neurology, 9(3), 145.
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12. Hopkins, R. D., & Brett, S. (2005). Chronic neurocognitive effects of critical illness. Curr Opin Crit Care 11(4), 369.
13. Stricker, K. H., Cavegn, R., et al. (2005). Does ICU length of stay influence quality of life? Acta Anaesthesiol Scand. 49(7), 975.
14. Granja, C., Dias, C., et al. (2004). Quality of life of survivors from severe sepsis and septic shock may be similar to that of others who survive critical illness. Crit Care, 8(2), R1.