Important complications of care in the intensive care unit (ICU) consist of infections including ventilator-associated pneumonia, catheter-associated bloodstream infections and urinary tract infections; venous thromboembolism, delirium, myopathies and neuropathies related to critical illness and stress ulcers.
Increasing attention is being given to long-term complications present in survivors of acute respiratory distress syndrome (ARDS) and other critical illnesses. Many patients who are critically ill in the ICU will not survive to return to their previous level of functional status, and muscle weakness and cognitive and neuropsychiatric complaints related to critical illness may decrease quality of life.
II. Identify the Goal Behavior
Hospital providers should be aware of the major complications of ICU care in order to implement evidence-based preventative measures when possible, to screen patients for complications after an ICU stay and to inform conversations with patients and families about goals of care.
III. Describe a Step-by-Step approach/method to this problem.
The major complications of critical illness and ICU care include the following:
This should be a consideration in goals-of-care discussions with families as they may not always appreciate the long-term consequences of a prolonged stay in the ICU, even if the patient does recover from the initial critical event. ICU survivors are two to five times more likely to die compared with age and sex-matched population controls. For example, in a prospective cohort study of 126 patients receiving prolonged mechanical ventilation only 9% were alive with no functional dependency at one year; 44% were dead, 21% were alive with complete functional dependency and 26% were alive with moderate dependency.
Consider early physical and occupational therapy in mechanically ventilated, critically ill patients. A randomized controlled trial in which mechanically ventilated patients received early physical and occupational therapy (including activities of daily living [ADL] and walking if tolerated) during interruptions of sedation while on mechanical ventilation showed an increase in return to independent functional status as well as shorter duration of delirium and more ventilator-free days in those receiving the intervention.
This is a serious complication of ICU care; prevention strategies include decreasing the length of mechanical ventilation through spontaneous breathing trials and interruption of sedation and the use of non-invasive ventilation when appropriate (see the chapter “Ventilator-associated pneumonia”).
Venous thromboembolism is relatively common in the ICU, with a prevalence of deep vein thrombosis (DVT) of about 30% according to one study. DVTs are often unrecognized in the ICU setting but are associated with an increased duration of mechanical ventilation and longer ICU stay. Consider pharmacologic venous thromboembolism (VTE) prophylaxis in all ICU patients; it is universally recommended for critically ill patients without contraindications (see the chapter “DVT prevention”).
Central venous catheter-associated bloodstream infections and urinary catheter-associated urinary tract infections are common in the ICU setting.
Consider placing central venous catheters in the subclavian vein when possible as this site has a lower infection rate. Other preventative measures include full barrier precautions during central venous catheter placement, cleaning the skin with chlorhexidine and removal of the catheter as soon as it is no longer indicated (see the chapter “Hospital-acquired Infections”).
Sixty to eighty percent of mechanically ventilated patients develop delirium and it is associated with prolonged mechanical ventilation, increased length of stay and increased mortality.
Consider using the Confusion Assessment Method for the ICU (CAM-ICU) instrument to screen patients for delirium in the ICU. Antipsychotics are commonly used to treat ICU delirium, but this practice is not supported by randomized controlled trials and these medications should be used sparingly. A double-blind, placebo-controlled randomized trial of the early use of haloperidol in critically ill patients did not support the hypothesis that haloperidol modifies the duration of delirium in critically ill patients. A meta-analysis of randomized controlled trials comparing the sedative dexmedetomidine with lorazepam, midazolam and propofol showed a decreased occurrence of delirium as well as shorter length of mechanical ventiliation with dexmedetomidine, as well as an increase in hypotension and bradycardia.
See the chapters “Delirium,” “In-hospital prevention,” and “Sedation, paralytics and analgesia.”
Studies suggest that 40 to 80% of patients surviving critical illness will have cognitive impairment a year after hospital discharge. Cognitive impairment is more common in the elderly, in those with prolonged ICU delirium, and among those with low premorbid cognitive reserve, but it is common in both older and younger patients in both surgical and medical ICU populations.
Delirium, hypotension, hypoxemia, prolonged sedation, and hypoglycemia may be important risk factors for cognitive impairment related to an ICU stay.
Consider a cognitive evaluation by a speech pathologist in the hospital or as part of post-acute care in patients who are recovering from critical illness.
Critically ill patients can develop gastric ulcers, which can cause a catastrophic gastrointestinal (GI) bleed. Acid-suppressive medication should only be used routinely in patients at high risk of developing stress ulcers because these medications may be associated with an increased risk of hospital-acquired pneumonia and Clostridium difficile infection.
Consider using proton-pump inhibitors or histamine H2 receptor antagonists for high-risk critically ill ICU patients including those who are expected to be mechanically ventilated for more than 48 hours, patients with a GI bleed in the past year and those with coagulopathy. Prophylaxis is also recommended for patients with two or more of the following risk factors: sepsis, ICU stay of more than a week, occult bleeding for 6 days or more, and use of high-dose corticosteroids. There is no strong evidence that proton-pump inhibitors are superior to histamine H2 receptor antagonists and they are more expensive.
Pharmacologic prophylaxis may not be beneficial in patients receiving enteral nutrition, but this has not been studied in randomized controlled trials. The medication should generally be stopped when the patient leaves the ICU; acid-suppressive therapy is not indicated for general medicine inpatients (see the chapter “In-hospital prevention”).
Affected patients exhibit symmetric motor deficits in all limbs and can be difficult to wean from the ventilator due to respiratory muscle weakness. Critical illness polyneuropathy (CIP) and critical illness myopathy (CIM) are two forms of this disorder. A trial of strict glucose control in critically ill surgical patients showed fewer cases of CIP in the intensive insulin therapy group.
Consider tight glucose control, although targets are controversial and hypoglycemia should be avoided (see the chapter “Glycemic control of the hospitalized patient”). Consider limiting patients’ exposure to neuromuscular blocking agents and corticosteroids when possible, as these agents may increase the risk of weakness (see the chapter “Critical illness polyneuropathy”).
ICU survivors are thought to have a higher risk of post-traumatic stress disorder (PTSD), anxiety, and depression. In one study of survivors of acute lung injury, 36% were found to have depression, about 40% anxiety, and 62% PTSD. Some studies suggest that limiting sedative exposure may reduce this risk.
Having a loved one in the ICU understandably causes considerable distress, and clear communication can be helpful. A proactive communication strategy including longer family conferences (median of 30 minutes), with time for families to talk (median of 14 minutes), as well as a brochure, decreased PTSD symptoms, anxiety and depression and complicated bereavement among family members. Palliative care consultation is increasingly available and studies suggest that proactive palliative care consultation may decrease length of stay and reduce the use of non-beneficial resources.
IV. Common Pitfalls.
Open communication between all members of the interdisciplinary team in the ICU including nurses, social workers, clinical pharmacists, and respiratory therapists is essential to both avoiding complications in the individual ICU patient and to conducting quality improvement aimed at reducing complications. The presence of all invasive lines should be noted each day and consideration for removal considered to decrease the risk of infectious complications.
V. National Standards, Core Indicators and Quality Measures.
There are no national/standards benchmarks for all of the complications of ICU care at this time.
VI. What's the evidence?
Balas, MC, Vasilevskis, EE, Olsen, KM. “Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle”. Crit Care Med. vol. 42. 2014. pp. 1024-1036.
Cook, DJ, Crowther, MA. “Thrombophylaxis in the intensive care unit: focus on medical-surgical patients”. Crit Care Med. vol. 38. 2010. pp. S76-S82.
Curtis, JR, Cook, DJ, Wall, RJ. “Intensive care unit quality improvement: a "how-to" guide for the interdisciplinary team”. Crit Care Med. vol. 34. 2006. pp. 211-218.
Desai, SJ, Law, TJ, Needham, DM. “Long-term complications of critical care”. Crit Care Med. vol. 39. 2011. pp. 371-379.
Girard, TD, Pandharipande, PP, Carson, SS. “Feasibility, efficacy and safety of antipsychotics for intensive care unit delirium: the MIND randomized, placebo-controlled trial”. Crit Care Med. vol. 38. 2010. pp. 428-437.
Hermans, G, De Jonghe, B, Bruyninckx, F. “Interventions for preventing critical illness polyneuropathy and critical illness myopathy”. Cochrane Database Syst Rev. vol. 1. 2014. pp. CD006832
Herridge, MS, Tansey, CM, Matte, A. “Functional disability 5 years after acute respiratory distress syndrome”. N Engl J Med. vol. 364. 2011. pp. 1293-1304.
Jackson, JC, Girard, TD, Gordon, SM. “Long-term cognitive and psychological outcomes in the awakening and breathing controlled trial”. Am J Respir Crit Care Med. vol. 182. 2010. pp. 183-191.
Klompas, M, Branson, R, Eichenwald, EC. “SHEA/IDSA Practice Recommendation: Strategies to Prevent Ventilator-Associated Pneumonias in Acute Care Hospitals: 2014 Update”. Infect Control Hosp Epidemiol. vol. 25. 2014. pp. 915-936.
Lautrette, A, Darmon, M, Megarbane, B. “A communication strategy and brochure for relatives of patients dying in the ICU”. N Engl J Med. vol. 356. 2007. pp. 469-478.
Lin, P, Chang, C, Hsu, P. “The efficacy and safety of proton pump inhibitors vs histamine-2 receptor antagonists for stress ulcer bleeding prophylaxis among critical care patients: a meta-analysis”. Crit Care Med. vol. 38. 2010. pp. 1197-1205.
Marik, PE, Vasu, T, Hriani, A. “Stress ulcer prophylaxis in the new millenium: a systematic review and meta-analysis”. Crit Care Med. vol. 38. 2010. pp. 2222-2228.
Mikkelsen, ME, Christie, JD, Lanken, PN. “The Adult Respiratory Distress Syndrome Cognitive Outcomes Study – long-term neuropsychological function in survivors of acute lung injury”. Am J Respir Crit Care Med. vol. 185. 2012. pp. 1307-15.
Norton, SA, Hogan, LA, Holloway, RG. “Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients”. Crit Care Med. vol. 35. 2007. pp. 1530-1535.
Page, VJ, Ely, EW, Gates, S. “Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled tria”. Lancet Respir Med. vol. 1. 2013. pp. 515-523.
Pandharipande, PP, Girard, JC, Jackson, A. “Long-term cognitive impairment after critical illness”. N Eng J Med. vol. 369. 2013. pp. 1306-1316.
Provonost, P, Needham, D, Berenholz, S. “An intervention to decrease catheter-related bloodstream infections in the ICU”. N Eng J Med. vol. 355. 2006. pp. 2725-2732.
Schweickert, WD, Pohlman, MC, Pohlman, AS. “Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial”. Lancet. vol. 373. 2009. pp. 1874-1882.
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