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KEY POINTS

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  • Between 5% and 10% of patients admitted to adult ICUs become chronically critically ill. The burden of chronic critical illness is anticipated to increase dramatically in the next decade as the population ages and more patients survive the acute phase of critical illness.

  • Advanced age and multiple organ failure due to severe sepsis and multiple trauma are the most significant risk factors for chronic critical illness, especially when complicated by comorbidities and nosocomial complications.

  • Chronically critically ill patients have distinct physiology compared with more acutely ill patients, including suppressed levels of anterior pituitary hormones, severe depletion of protein stores with muscle wasting, and relative immune compromise.

  • Important principles of patient management include prevention of infection, protein repletion, limitation of sedating medications, aggressive physical therapy, and careful attention to treating pain and depression.

  • Liberation from mechanical ventilation is usually achieved with work-rest cycles that are guided by frequent assessments of readiness for weaning and careful monitoring to avoid fatigue. Weaning protocols that include daily periods of unassisted breathing are more efficient than protocols that are based on gradual decreases in pressure support ventilation.

  • One-year survival for chronically critically ill patients is between 40% and 50% in most cohorts.

  • Chronically critically ill patients experience a median of four transfers of care after acute hospital discharge, and 74% of days alive during the subsequent year are spent in institutionalized care or receiving professional care at home. After 1 year, only 10% of patients are alive and functionally independent at home.

  • Costs of care for chronically critically ill patients are extreme during hospitalization and after discharge. Cost savings can be achieved by managing hemodynamically stable patients in dedicated wards or facilities outside of the acute ICU setting with lower nurse-to-patient ratios.

  • There is often significant discordance in understanding of long-term outcomes between surrogate decision makers and clinicians. The ProVent Score, a validated clinical prediction rule for long-term mortality in chronically critically ill patients, can inform discussions of prognosis in shared decision making.

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INTRODUCTION

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Advances in medical management and technology have greatly enhanced patients' ability to survive critical illness and injury. For most critically ill patients, the clinical course is typified by liberation from organ support systems such as vasoactive drugs and mechanical ventilation after reversal of the acute process, followed by a short period of observation before transfer from the ICU to a medical/surgical ward or an intermediate care unit. For a significant number of patients, however, this timely transition to a more stable condition does not occur, and they remain dependent on life-support systems or other ICU services for prolonged periods. These patients often are referred to as the chronically critically ill (CCI). As larger proportions of aging patients are surviving episodes of severe sepsis, the acute respiratory distress syndrome (ARDS), multiple trauma, or acute on chronic respiratory failure, CCI patients are becoming a significant component of the practice of critical care medicine.

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CCI ...

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