Chapter 18

• Chronically critically ill patients account for 5% to 10% of patients admitted to an adult ICU. They account for as many as 88,000 hospital discharges per year in the United States. Most chronically critically ill patients are over age 65. The burden of chronic critical illness is anticipated to increase dramatically in the next decade.
• Chronically critically ill patients have distinct physiology compared with more acutely ill patients, including suppressed levels of anterior pituitary hormones and severe depletion of protein stores with muscle wasting.
• Important principles of patient management include prevention of infection, protein repletion, aggressive physical therapy, and careful attention to treating symptoms.
• Liberation from mechanical ventilation usually is achieved with work-rest cycles that are guided by frequent assessments of readiness for weaning and careful monitoring to avoid fatigue.
• One-year survival for chronically critically ill patients is between 23% and 38% in most cohorts, but younger patients with few comorbidities have distinctly better chances of survival. Quality of life for survivors is similar to that of patients with shorter periods of critical illness.
• Costs of care for chronically critically ill patients are extreme during hospitalization and after discharge. Cost savings can be achieved by managing patients in dedicated wards or facilities outside of the acute ICU setting.

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 patients are surviving episodes of severe sepsis, acute respiratory distress syndrome (ARDS), multiple trauma, or acute or chronic respiratory failure, CCI patients are becoming a significant component of the practice of critical care medicine.

CCI patients are recognized more easily than defined. Every clinician in the ICU is familiar with the patient who has been supported through the initial period of hemodynamic, neurologic, or respiratory instability that characterized their first few days in the ICU but whose continued recovery has been arrested by the persistence of the acute insult, new complications, or decompensation of severe underlying comorbidities. The patient is weak and frequently dependent on mechanical ventilation. A tracheostomy is present or being contemplated. Such patients are often delirious, if not minimally responsive, and the more alert among them are troubled by significant discomfort. Their physical appearance is altered by muscle atrophy and diffuse edema. They are often cycling through recurring infections, multiple antibiotics, and evolving resistant organisms. Their families are distressed, frustrated, and exhausted. Finally, their ...

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