Common problems after ICU

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Chapter 8 Common problems after ICU

Until recently, an intensive care unit (ICU) stay was deemed successful if a patient survived to go to the ward. No consideration was taken of the patient dying on the ward or soon after leaving hospital or indeed if the patient went home with an appalling quality of life.

Mortality figures for patients leaving our own ICU recently are shown in Figure 8.1.

Figure 8.1 Mortality rates for leaving the intensive care unit (ICU).

A Kings Fund report ¹ in 1989 concluded that it was necessary to look at the morbidity following critical illness as well as mortality: ‘There is more to life than measuring death’.

Publications such as that of the Audit Commission (Critical to Success)² and that of the National Expert Group³ (Comprehensive Critical Care) have supported the development of follow-up for patients following a stay in intensive care. In 2007, the National Institute for Clinical Excellence (NICE) began to take an interest in the rehabilitation of critically ill patients and it is hoped will make recommendations to facilitate the introduction of follow-up programmes in all hospitals looking after critically ill patients.

In Reading, a follow-up programme has been ongoing since 1993. Until recently the rehabilitation of patients after a critical illness has fallen between too many stools. Following multiorgan dysfunction, it is difficult to categorise a patient to an individual specialty such as cardiac, respiratory or the stroke rehabilitation teams. Family doctors often have difficulty taking on the complexity of these patients, with the result that they are denied vital advice and assistance and lack an advocate with ‘teeth’ to ensure timely help.

SETTING UP A FOLLOW-UP SERVICE

Funding such a follow-up programme has posed local problems in many trusts. The service in Reading was initially approved and funded by local then regional audit committees.

The service is staffed by a follow-up sister who spends most of her time in this role helped by a staff nurse and an ICU consultant for the clinics held as a formal outpatient clinic 2/3 times monthly.

Patients who were in ICU for more than 4 days are seen in clinic at 2 months, 6 months and 1 year after discharge and, occasionally, we see patients who have been in ICU for a shorter time period and we also see referrals from other hospitals where follow-up isn’t happening. It is important to identify clerical and IT support, and to achieve good collaboration with other hospital departments and general practitioners (GPs) to ensure patients do not make unnecessary journeys to the hospital, by trying to coordinate their visits and ensuring that transport is organised where necessary. Very often, patients will voluntarily come from long distances if they had initially been admitted from other geographical locations – out-of-area transfers.

The logistics of running the service include arranging specific tests that may be required for the visit, such as pulmonary function tests, swabs for methicillin-resistant Staphylococcus aureus (MRSA), blood/urine for creatinine clearance. There may be special tests such as magnetic resonance imaging (MRI)⁴ for patients who had a tracheostomy during their stay in ICU.

The service in Reading costs £30 000 annually which, in the context of the bigger picture (£4.5 million budget for our ICU), is a small price to pay (Figure 8.2). An unexpected bonus is that the clinic is often seen by the patients as a convenient place to make donations to the ICU.

Figure 8.2 Costs of running a service.

SPECIFIC PROBLEMS POST-ICU

The range of problems seen after intensive care is vast and ranges from nightmares and sleep disturbance through to ill-fitting clothes. Many of the problems are very specific to the individual but there are also recurrent themes. Flashbacks are common, as are taste loss, poor appetite, nail and hair disorders and sexual dysfunction.

There are several quality-of-life tools used in follow-up studies (Table 8.1). Objective measurements may be inappropriate because they look at aspects such as return to work: often, patients in their 50s may not return to work after a traumatic episode, including ICU, and subjective measures would be more applicable, such as Perceived Quality Of Life (PQOL).

Table 8.1 Quality-of-life tool examples

Objective
QALY	Quality of Life tool⁵
Subjective
HAD	Hospital Anxiety and Depression⁶
PQOL	Perceived Quality of Life⁷
EuroQol	‘European’ tool⁸
SF 36	36-item short-form survey⁹

TRACHEOSTOMY

Since percutaneous techniques performed by intensivists started to replace surgical tracheostomy in 1991, we have seen an increasing number of patients tracheostomised earlier in their ICU stay.

The long-term sequelae have been assessed by lung function tests, nasoendoscopy and MRI screening (Figure 8.3). There are minor cosmetic problems, such as tethering (Figure 8.4). Tethering is easily dealt with in ear, nose and throat outpatients under local anaesthetic.

Figure 8.3 Assessment of long-term sequelae.

Figure 8.4 Tethering.

More difficult to manage is tracheal stenosis, defined as a 15% reduction in tracheal diameter. However, there have only been two cases to date. These were seen in the first series of 30 cases.⁴

MOBILITY

Even in the absence of trauma, patients can expect to need 9 months to 1 year to regain full mobility. This is usually due to a mixture of joint pain, stiffness and muscle weakness. In one study,¹⁰ the duration of ICU stay was associated with mobility problems probably associated with loss of muscle mass. If questioned, patients will often report climbing stairs on all fours and descending on their bottoms (Figure 8.5). Muscle wasting can present as a severe localised problem.

Figure 8.5 Climbing and descending stairs.

This may be associated with critical illness polyneuropathy (CIP),¹¹ which not only prolongs ventilatory weaning but frequently both complicates and delays rehabilitation. Muscle relaxants have been implicated in the development of CIP¹² but have not been shown to be statistically significant in terms of delayed weaning of intermittent positive-pressure ventilation and duration of stay in ICU.¹³

Until now, there have been no specific rehabilitation programmes for patients recovering from critical illness, although rehabilitation programmes for heart attack, stroke and respiratory disease are well established. A three-centre study has shown that a self-help physiotherapy guided rehabilitation exercise programme will speed up physical recovery after intensive care.¹⁴

It is important for a member of the team to try and spend time with patients at their homes to assess their special needs and liaise with the GPs, district nurses, community physiotherapists and occupational therapists.