Long-Term Outcomes of ICU Patients

LONG-TERM OUTCOMES OF ICU PATIENTS

The intensive care unit (ICU) serves to provide acute care to patients with severe and life-threatening illnesses or injuries that require immediate care, as well as close and constant monitoring. Once the patient has recovered from the inciting insult, they are discharged to the floor, often lost to follow-up. The ICU treats various complicated conditions, but not much information is provided to clinicians in the ICU about the long-term outcomes of our patients. Over the past 50 years in trauma and ICU care, there has been a paradigm shift in outcome assessment from that of pure mortality–survival (i.e. death or life), to specific morbidity for the survivors. Progress continues in this area as we attempt to show functional gains and abilities in the continuum of care, from ICU to community. This chapter serves to discuss the long-term outcomes of ICU patients who survive trauma, acute respiratory distress syndrome (ARDS), sepsis, and traumatic brain injury (TBI)—some of the most common conditions encountered in this setting.

I. TRAUMA

A. Trauma can range from blunt trauma (e.g., motor vehicle accidents, falls), to penetrating trauma (e.g., gunshot, stab wounds).

1. The established studies do not differentiate between blunt and penetrating trauma, but “major trauma in the ICU” is associated with the following:

a. Requiring urgent surgery

b. Admission to an intensive care unit for >24 hours

c. Requiring mechanical ventilation

d. An injury severity score >15

e. Death occurring after injury.

B. The available data suggest that the trauma population is greatly affected in all aspects of life postdischarge from the ICU, and in all measured dimensions the scores are lower than the general population. These effects are most pronounced within the first year, but scores remain consistently low even after several years.

1. One reason for such a drastic change is that trauma patients are usually previously healthy individuals (compared with, for example, septic patients), so the changes in quality of life seem drastic.

2. As a general rule many of our trauma patients are of a younger age, with vocational and social expectations at prime time in their lives, and taking this into consideration with respect to return to work, pain issues, emotional and social health, and so forth is essential.

C. Trauma ICU survivors consistently have a lower health-related quality of life (QOL) in the years after ICU discharge. Although QOL is certainly subjective, the most common measurement tool for QOL is the Short Form 36 Health Survey (SF-36) questionnaire, which evaluates individual health status, enables comparison across diseases or injuries, and determines how QOL is affected by treatment.

1. The eight sections included (each with a score 0–100; the lower the score, the greater the disability) are vitality, physical functioning, bodily pain, general health perception, physical role functioning, emotional role functioning, social role functioning, and mental health.

2. In short-term follow-up (3–12 months after ICU discharge), an increase in physical function, bodily pain, and social functioning scores was observed in one study but the scores plateaued by 12 months and of note were still consistently lower than the general population.

3. After 2 years of follow-up, a large decrease in HRQOL was also evident, predominantly in the physical dimensions section, which was attributed to musculoskeletal effects and secondary pain. Extending the follow-up period even further to 7 years demonstrated the same results.

4. Demographics (age, area of the country, personal wealth), trauma characteristics (MVA vs. violence related), the injury severity score, preexisting disease (especially psychological disorders and abuse problems), and pain issues were all shown to be predictors of poor HRQOL among trauma survivors.

5. Patients who obtained higher levels of education, had greater family and social support, and better material and housing conditions were perhaps predisposed to optimism and might “see the positive side of things after a severe illness”.

D. ICU survivors of trauma had a lower incidence of returning to work and a higher incidence of early retirement compared with the nontrauma, non-ICU general population.

1. Only 52% of survivors returned to work (of the approximately 80% who survived after the ICU) and 20% pursued an early retirement.

2. The odds of returning to work increased within the first year after ICU discharge but plateaued after 12 months. Again, pain and physical disability were the main reasons for a lower return-to-work rate.

3. Interestingly, spouses and close family members of trauma survivors had a low rate of return to work. This may speak to the “outcome” of primary care givers themselves in the home and care giver burden.

E. Importantly, a common theme found between studies was an increased incidence of chronic pain after trauma. Pain scores were reported to be the highest during the 6-to-12-month period after ICU discharge, with mild improvement after 12 months. The only reliable predictor identified for the development of chronic pain was the prevalence of pain prior to trauma.

F. Physical and emotional recovery from a significant trauma can take multiple years. The vast majority of studies only looked at the first year after injury. The trend of HRQOL, return to work, and chronic pain within the first decade after injury might be more informative. However, such long-term follow-up is difficult to perform once the patient has been discharged.

II. ACUTE RESPIRATORY DISTRESS SYNDROME

ARDS is an inflammatory process in the lungs that significantly reduces gas exchange and can be triggered by infection, sepsis, or trauma. Recovery from ARDS can be more extensive than recovery from sepsis or trauma in that patients must overcome the initial insult and then recover from the massive insult to their lungs, which includes mechanical ventilation in and of itself, excessive fluid requirements, and relative hypoxemia. As a result, patients can have significant impairment after discharge that can last for months to years.

A. Survivors of ARDS have poorer HRQOL compared with the general population. The main features affected are mobility, energy, social relationships, domestic tasks, and professional tasks. Mobility is greatly impaired in patients with long ICU and hospital courses, and especially in those who have had long intubation or sedation times. Although modern ICU treatment supports early mobilization, there is indeed significant relative immobilization, which quickly can lead to deconditioning of the muscle, bone and joints, soft tissue, skin, and cardiovascular systems in particular. Overcoming ICU-acquired weakness after ARDS requires weeks to months of rehabilitation and depending on functional level of the patient post-ICU will require admission to a rehabilitation hospital or discharge home with planned outpatient therapies.

B. Fatigue or “lack of energy” are common long-term complaints experienced post-ARDS treatment that likely has multifactorial contributions (e.g., direct sarcopenia, decreased sleep secondary to other impairments, low cardiopulmonary endurance, depression). Social and family relationships can be affected because patients are in the acute care hospital and potentially rehabilitation hospital undergoing treatment and are discharged to recuperate at home following weeks to months of relative isolation, and relationships can be strained. In addition, patients may feel they are a burden to their family, or caretakers may feel resentful for having to give up their time, job, and money to care for the patient.

C. The incidence of depressive symptoms in the ARDS population is increased. Recovery is long and grueling, which can be a significant stressor or trigger for depression. Some patients lack the necessary social support to get through their recovery, which compounds the problem further.

D. ARDS causes significant damage to the lungs and adversely affects pulmonary physiology. Survivors typically can regain baseline or normal pulmonary function after 12 months, and strict follow-up with imaging and pulmonary function tests after discharge are needed. Follow-up studies and appointments are expensive and the time and commitment required to make the appointments is significant, which may contribute to the lack of return to work.

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