Chronic Critical Illness

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Chronic Critical Illness

• Presented by Jennifer Young MSN, BSN, RN
• Transitional Care Coordinator

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• OBJECTIVES
• The participant will be able to define Chronic
  Critical Illness.
• The participant will understand the historical
  significance of Chronic Critical Illness.
• The participant will understand the features and
  presentation of Chronic Critical Illness.
• The participant will be able to identify
  individuals that may have or are inclined to
  develop Chronic Critical Illness.
• The participant will be able to discuss the
  doctrines of care for the patient with Chronic
  Critical Illness.
• The participant will be able to discuss and
  utilize the post-acute continuum of care for a
  patient with Chronic Critical Illness.

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Definition of Chronic Critical Illness

• Chronic Critical Illness (CCI) is a distinct and
  intricate syndrome of physiologic dysfunctions,
  organ hindrances, neuroendocrine and immunologic
  changes.
• Unknown as to the specific trigger that starts
  CCI.
• Prolonged inflammation

• Patients with CCI are found to be in the chronic
  state while continuing on acute life sustaining
  machines.
• Time frame 7-14 days?
• The law of unintended consequences.
• Advanced life supporting abilities.

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History

• In 1985 the term CCI was coined by Girard and
  Raffin who wrote the words in regards to CCI to
  live or let die.
• Systemic Inflammatory Response (SIRS)
• Multi-organ Dysfunction Syndrome (MODS)
• Together SIRS and MODS help describe CCI.

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Demographics

• Estimates indicate that there are more than
  100,000 patients with CCI in the US at any given
  point. (this number will be growing due to the
  baby boomer population)
• Cost exceeding 20 billion each year for the US
  health care system

• Hospital re-admission rates one year after
  hospital discharge exceeds 40.
• Fewer than 12 of CCI patients survive 1 year
  out.

Nelson, J.E., Cox, C.E., Hope, A.A., Carson, S.S.
Chronic Critical Illness. American Journal of
Critical Care Med. Aug. 15, 2010 182(4) 446-454
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Features of CCI

• ICU patients
• Typically 65 and older
• Underlying chronic illness or co-morbidity
• Unstable
• Prolonged need for medical and nursing care
• Uncertain course or recovery.
• On set of CCI occurs 7-14 days after the initial
  onset of acute illness, insult or injury.

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CCI Presentation

• Fluid imbalance
• Overload, Anasarca, Edema
• Nutritional Deficits
• Critical myopathy
• Skin impairment
• Anemia
• Muscle loss
• Immune system depression
• Neuro-endocrine dysfunction
• Sleep impairment/insomnia
• Cognitive impairment
• Anxiety, Depression, Confusion, ICU psychosis.

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CCI Presentation

• Profound burden of suffering

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Patients

• Prolonged Mechanical Ventilators
• Defined by a patient being on the Ventilator for
  6 hours or more per day for 21 days.
• Chronic conditions with exacerbations
• Organ dysfunction
• Renal
• Heart
• Brain
• Infectious disease
• Severe wounds
• Septic patients

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Pathophysiology
HPA Axis Activated by stress, acute
insult, Other injury, or illness. This is a
normal response. Anti-inflammatory
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Pathophysiology
Adrenal Gland
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Pathophysiology
Cortisol affects the Renin-Angiotenson-Aldosterone
system.
Skin fragility and increased risk for pressure
ulcers
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Pathophysiology
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Pathophysiology
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HPA AXIS
Systemic Inflammatory response If this response
is not turned off it will lead to multiple
organ dysfunction.
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Pathophysiology

• Ways to monitor the HPA Axis
• CRP (C-Reactive Protein)
• Albumin
• Procalcitonin
• All proteins affected by cortisol and they can be
  used to track disease progression.

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Pathophysiology
Pro-inflammatory process
Immune Response
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Pathophysiology
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Pathophysiology
Anti-Inflammatory
Pro-inflammatory
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Doctrines of Care

• Reduce the inflammatory response.
• Mobility early
• Even if on a ventilator
• Nutritional
• support early
• Ventilator weaning
• Sedation vacation
• Prevent further complications
• Law of unintended consequences.

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Doctrines of Care

• Multidisciplinary Teams
• Physicians
• Nurses
• Case Manager
• Social Worker
• Respiratory Therapist
• Physical Therapist
• Nutritionist
• Pharmacy

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Continuum of Care

• Palliative Care with restoration
• LTACH
• SNF
• Hospice
• Home with Home Health
• Home

• All of these options need to be discussed open
  and honestly with each patient by all members of
  the Multidisciplinary team.
• Being a Patient Advocate is knowing the resources
  and options.

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Conclusion

• Caring for the patient with Chronic Critical
  Illness is delicate and timely. These patients
  and families are traumatized by what they are
  facing and the fear of the unknown road that is
  ahead of them.

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References.

• Girard K, Raffin TA. The chronically critically
  ill to save or let die? Respir Care
  198530339347.
• Nelson, J.E., Cox, C.E., Hope, A.A., Carson, S.S.
  Chronic Critical Illness. American Journal of
  Critical Care Med. Aug. 15, 2010 182(4)
  446-454.