ron lm recovered file 2015
TRANSCRIPT
Clinical meaningful outcomes after pARDS
Francois Aspesberro, MDPediatric Critical Care Medicine
Seattle Children’s HospitalUniversity of Washington School of Medicine
Seattle, WA
Critical care begins and ends outside the walls of the PICU
Angus DC et al. Intensive Care Med 2003;29:368-377
Historical Decline of PICU Mortality
Aspesberro F, Mangione-Smith R, Zimmerman JJ. Intensive Care Med 2015 July;41(7):1235-1246
Pediatric critical care has exchanged mortality for morbidity
Mortality
Morbidity
Simon DW et al. Pediatr Crit Care Med 2014;15(3):264-266
Post Intensive Care Syndrome PICS
Needham DM, Davidson J, Cohen H, et al:. Crit Care Med 2012;40:502-509
pARDS mortality rates 1980-2007
Zimmerman JJ, Akhtar Z, Caldwell E, Rubenfeld GD. Pediatrics 2009;124:87-95
pARDS mortality rates 1993 - 2013
Quasney MW, Lopez-Fernandez YM, Santschi M, Watson RS. Peds Crit Care Med 2015;16(5Supl1):S23-40
Risk Factors for ARDS Mortality
ImmunodeficienciesHematologic malignanciesHSCTDICMODSSepsis (indirect lung injury)History of lung diseasePreexisting chronic organ dysfunctionDegree of hypoxemia
Quasney MW, Lopez-Fernandez YM, Santschi M, Watson RS. Peds Crit Care Med 2015;16(5Supl1):S23-40Erickson S, Schibler A, Numa A, Nuthall G et al. Peds Crit Care 2007;8:317-323
pARDS Mortality and MODS
Lopez-Fernandez Y, Martinez-de Azagra A, de la Oliva P et al. Crit Care Med 2012;40:3238-3245
pARDS Mortality and Hypoxemia
Lopez-Fernandez Y, Martinez-de Azagra A, de la Oliva P et al. Crit Crae Med 2012;40:3238-3245
pARDS Mortality and Hypoxemia
Yehya N, Servaes S, Thomas NJ. Crit Care Med 2015;43:937-946
“ Despite resounding evidence that there are significant long-term consequences in
adult ARDS survivors, the long-term consequences of pARDS remain largely
unknown.”
Quasney MW, Lopez-Fernandez YM, Santschi M, Watson RS. Peds Crit Care Med 2015;16(5Supl1):S23-40
Pulmonary Function after ARDS
FEV1FVCTLCDLCOExercise limitation (distance walked in 6 min)
Pulmonary Function in ARDS Survivors
McHugh LG, Milberg JA, Whitcomb ME, et al. Am J Respir Crit Care Med 1994;150(1):90-4
Pulmonary Function in ARDS Survivors
Toronto ARDS Study
“… relatively young (median age, 45 years) previously working patients with few comorbidities and without documented preexisting lung disease, regain normal or near-normal function …”
Herridge MS, Tansey CM, Matte A, et al. Functional disability 5 years after ARDS. NEJM 2011;364:1293-1304
Toronto ARDS StudyN=25 patients Chest CT Between 2-year and 5-year follow-upMost common minor findings: non-dependent pulmonary fibrotic changes (VILI)(1/3) bronchiectasis, new pulmonary fibrosis, bullae, pleural thickening
Herridge MS, Tansey CM, Matte A, et al. Functional disability 5 years after ARDS. NEJM 2011;364:1293-1304
Changes in Lung Parenchyma after ARDS
Nöbauer-Huhmann et al. 2001First one to perform HR-CT N=156-10 months after ARDS
Nöbauer-Huhmann IM, Eibenberger K, Schaefer-Prokop C et al. Eur Radiol 2001;11:2436-2443
Hila levelLocalized parenchymal opacification
Traction bronchiectasis Local fibrosis
Upper lobes levelArchitectural distortionHoneycomb pattern
Upper lobes levelGround glass opacitiesThickened IL septa
Functional Disability after ARDS
Rapid disuse atrophy of diaphragm fibers in mechanically ventilated
humans
Intraoperative biopsy specimens from the diaphragmsN=14 brain dead organ donors (18 - 69h diaphragm inactivity and mechanical ventilation)N=8 control subjects undergoing surgery
Levine S, Nguyen T, Taylor N, et al. NEJM 2008;358:1327-1335
Risk Factors for Critical Illness Myopathy
1. MODS/severity of illness2. Muscle inactivity3. Hyperglycemia4. Corticosteroids5. Neuromuscular blockers
de Jonghe B, Lacherade JC, Sharshar T, Outin H. Crit Care Med 2009;37:S309-S315
Qualitative ultrasound in acute critical illness muscle wasting
US echogenicity assessment of Rectus FemorisMuscle bx of Vastus LateralisN=15Significant correlation between US echogenicity and myofiber necrosis
Early and rapid loss of skeletal muscle mass Skeletal muscle function depends on its quantity and quality
Puthucheary ZA, Phadke R, Rawal J et al. Crit Care Med 2015
Day 1 Day 10
Acute Muscle Wasting in Critical Illness
N=63, mean age 55, APACHE II 23.5>48 h MV, projected ICU LOS > 7 days, survive ICU d/cUS cross-sectional area CSA of the Rectus FemorisMuscle protein synthesis and breakdown rates
Muscle wasting occurred early and rapidly during 1st weekMore severe with MOFBalance of protein synthesis/breakdown: catabolic state
Puthucheary ZA, Rawal J, McPhail M, et al. JAMA 2013;310(15):1591-1600
Herridge MS, Cheung AM, Tansey CM, et al. NEJM 2003;348(8):683-93
Acute Muscle Wasting in Critical Illness
ICU-acquired weaknes
s
Irreversible
functional disability
Survival rates; Kaplan-Meier curve
6- Minute walk distance
HRQOL; SF-36 subscale scores for physical and mental componentHerridge MS, Tansey CM, Matte A, et al. Functional disability 5 years after ARDS. NEJM 2011;364:1293-1304
Neuromuscular Dysfunction
Confusing terminologyCritical illness neuropathy or polyneuropathyCritical illness myopathyICU-acquired paresis ICU-acquired weaknessCritical Illness Neuro-Muscular Abnormalities CINMA
Muscle and nerve lesions often coexist
Critical Illness Polyneuropathy
Systematic review by Stevens et al. N=1400 critically ill patientsCINMA incidence of 50%Common: SIRS. SEPSIS, ARDSDiagnostic tests: nerve conduction, velocities, needle electromyography, direct muscle stimulation, histopathology of muscle or nerve tissue
Stevens RD, Dowdy DW, Michaels RK, et al. Int Creae Med 2007;33:1876-1891
Critical Illness Polyneuropathy
Difficult to identify weakness in unresponsive or minimally interactive critically ill patientsEMG:
1. Primary axonal degeneration of the motorneurons2. Followed by sensory neural fibers
Additional Physical Morbidities
Entrapment neuropathy - prevalence 6% at 1-year follow-up (Toronto study) - peroneal and ulnar nerve palsies - preclude return to work - resolved by 5 years
Heterotopic ossification - deposition of para-articular ectopic bone - associated with polytrauma, burns, pancreatitis and ARDS
Cosmetic - scars: laparotomy, chest tube, AL, CVL, tracheostomy, burns, striae from fluid overload, facial scars from NIMV
Additional Physical Morbidities
Tracheal stenosis/malaciaTracheal resectionTracheostomyContracturesFrozen shouldersHoarsenessVoice changesTooth lossSensorineural hearing lossTinnitusEmotional outcomesSocial isolationSexual dysfunction
Hopkins RO, Weaver LK, Pope D, et al. Am J Respir Crit Care Med 1999;160:50-56
N=55 ARDS survivors at 1-year ICU dischargeHospital d/c: 100% cognitive impairments (memory, attention, or concentration)1-year f/u: 78% impairment at least one cognitive function
48% decreased speed of mental processing Neurocognitive dysfunction impacts HRQOL
Psychiatric MorbidityToronto ARDS study50% patients depression or anxiety between 2-5 years after ICU discharge
Schelling, Gustav; Stoll, Christian; Haller, Mathias; et al. Crit Care Med 1998 26(4):651-659
Cohort of 80 ARDS patients (2 control groups)
4 years following discharge
PTSS-10 Post Traumatic Stress Syndrome 10-Questions Inventory
1/3 ARDS survivors reported compromised memory, disturbing dreams, anxiety, and sleeping difficulties
Risk Factors for PTSD, Depression and Anxiety
Delusional memoriesMemory for nightmaresComplete absence of any ICU memoryHx of psychopathologyPsychotic experiencesGreater ICU Benzodiazepine exposure
ICU diaries that contained information and photographs from the ICU stayN=352 were randomized at 1 month following ICU dischargeFinal PTSD assessment at 3 months
Caregiver and Family Burden
60% survivors who received long-term MV still required assistance of a family caregiver 1 year after dischargeExperience burden from patient’s physical and psychological dysfunctionLifestyle disruptionPTSDEmotional distressDepressionAnxiety Chelluri L, Im KA, Belle SH, et al. Crit Care Med 2004;32(1):61-9
Cameron JI, Herridge MS, Tansey CM, et al. Crit Care Med 2006;34(1):81-6Foster M, Chaboyer W. Scand J Caring Sci 2003;17(3):205-14Douglas SL, Daly BJ, Kelley CG, et al. Chest 2005;128(6):3925-36Pochard F, Darmon M, Fassier T, et al. J Crit Care 2005;20(1):90-6
Caregiver and Family Burden
Pochard F, Azoulay E, Chevret S, Lemaire F, Hubert P, Canoui P, et al. Crit Care Med 2001, 29(10):1893-1897
HRQOL after ARDS
HRQOL after ARDSLower HRQOL scores in ARDS survivorsLargest decrement:
- Role-physical- Physical functioning- Social functioning Important patient-centered metric of recovery
Schelling, Gustav; Stoll, Christian; Haller, Mathias; et al. Crit Care Med 1998 26(4):651-659Davidson TA, Caldwell ES, Curtis JR, et al. JAMA 1999;281(4):354-360Angus DC, Musthafa AA, Clermont G, et al. Am J Resoir Crit Care Med 2001;163(6):1389-94Dowdy DW, Eid MP, Dennison CR, et al. Intensve Care Med 2006;32(8):1115-24Orme J, Romney JS, Hopkins RO, et al. Am J Respir Crit Care Med 2003;167(5):690-4
HRQOL after ARDSAdversely influenced by physical and neuropsychological morbiditiesAn episode of severe lung injury changes the trajectory of functional outcomeMay necessitate a change in employment
Raise awareness among the critical care community
regarding long-term morbidity
ConclusionsDevelopment of specialized pediatric intensive care has contributed to substantially reduced mortality for children with pARDS over the past few decades.
Recent publications suggest that pediatric critical care may have “exchanged” decreased mortality for increased long-term morbidity.
The ‘Post Intensive Care Syndrome’, first described in adults, may also occur in this vulnerable population of children.
ConclusionsRecent research has identified physical, cognitive, and mental health domains as the major areas of impairment in survivors of critical illness.There is an urgent need for additional clinical research to better characterize PICS and its risk factors towards a goal of minimizing adverse sequelae associated with critical illness.
FutureIdentify PICU survivors most at risk.Characterize long-term outcomes.Generate recovery curves for various illnesses.Identify factors associated with long-term morbidity and recovery.Define potential targets for intervention.
Words of Wisdom
“ Ultimately, maximizing long-term FS and HRQOL should be the most important goals of critical care medicine. “ Dr. J Zimmerman