Chronic Critical Illness
Presented by: Jennifer Young MSN, BSN, RN
Transitional Care Coordinator
OBJECTIVES
1. The participant will be able to define Chronic Critical Illness.
2. The participant will understand the historical significance of Chronic Critical
Illness.
3. The participant will understand the features and presentation of Chronic
Critical Illness.
4. The participant will be able to identify individuals that may have or are
inclined to develop Chronic Critical Illness.
5. The participant will be able to discuss the doctrines of care for the patient
with Chronic Critical Illness.
6. The participant will be able to discuss and utilize the post-acute continuum
of care for a patient with Chronic Critical Illness.
Definition of Chronic Critical
Illness
• Chronic Critical Illness (CCI)
is a distinct and intricate
syndrome of physiologic
dysfunctions, organ
hindrances, neuroendocrine
and immunologic changes.
• Patients with CCI are found to
be in the chronic state while
continuing on acute life
sustaining machines.
• Unknown as to the specific
trigger that starts CCI.
• The law of unintended
consequences.
• Prolonged inflammation
• Time frame 7-14 days?
– Advanced life supporting
abilities.
History
• In 1985 the term CCI was coined by Girard and Raffin who wrote
the words in regards to CCI “to live or let die”.
• Systemic Inflammatory Response (SIRS)
• Multi-organ Dysfunction Syndrome (MODS)
– Together SIRS and MODS help describe CCI.
Demographics
• Estimates indicate that there
are more than 100,000
patients with CCI in the US
at any given point. (this
number will be growing due
to the baby boomer
population)
• Hospital re-admission rates
one year after hospital
discharge exceeds 40%.
• Fewer than 12% of CCI
patients survive 1 year out.
• Cost exceeding $20 billion
each year for the US health
care system
Nelson, J.E., Cox, C.E., Hope, A.A., Carson, S.S. Chronic Critical Illness. American Journal of Critical Care Med.
Aug. 15, 2010: 182(4): 446-454
Features of CCI
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ICU patients
Typically 65 and older
Underlying chronic illness or co-morbidity
Unstable
Prolonged need for medical and nursing care
Uncertain course or recovery.
On set of CCI occurs 7-14 days after the initial onset of acute
illness, insult or injury.
CCI Presentation
• Fluid imbalance
– Overload, Anasarca, Edema
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Nutritional Deficits
Critical myopathy
Skin impairment
Anemia
Muscle loss
Immune system depression
Neuro-endocrine dysfunction
Sleep impairment/insomnia
Cognitive impairment
– Anxiety, Depression, Confusion, ICU psychosis.
CCI Presentation
Profound burden of suffering
Patients
• Prolonged Mechanical Ventilators
– Defined by a patient being on the Ventilator for 6 hours or
more per day for 21 days.
• Chronic conditions with exacerbations
• Organ dysfunction
– Renal
– Heart
– Brain
• Infectious disease
• Severe wounds
• Septic patients
Pathophysiology
HPA Axis
Hypothalamus
Activated by stress, acute insult,
Other injury, or illness.
This is a normal response.
Anti-inflammatory
Pituitary Gland
Adrenal Gland
Pathophysiology
Adrenaline
Adrenal Gland
Cortisol
Pathophysiology
Cortisol affects the Renin-AngiotensonAldosterone system.
Cortisol
Water
Retention
Vascular
Contractility
Skin fragility and increased
risk for pressure ulcers
Pathophysiology
Pituitary
Corticotrophin
Vasopressin
Pathophysiology
Vasopressin
Vasoconstriction
Reduced
Tissue
perfusion
Muscle
Wasting
HPA AXIS
Hypothalamus
Systemic Inflammatory
response: If this response is
not “turned off” it will lead to
multiple organ dysfunction.
Pituitary
Adrenal
Pathophysiology
• Ways to monitor the HPA Axis
– CRP (C-Reactive Protein)
– Albumin
– Procalcitonin
• All proteins affected by cortisol and they can be
used to track disease progression.
Pathophysiology
Sympathetic
Nervous
System
Nor
Epinephrine
Immune Response
Autonomic
Nervous
System
WBC
Pro-inflammatory process
Epinephrine
Pathophysiology
WBC
Cytokines
Affect the production
of HPA proteins,
Catecholamine's &
Cortisol
Chemokines
Affect the production
of HPA proteins,
Catecholamine’s &
Cortisol
Pathophysiology
NeuroEndocrine
HPA Axis
Anti-Inflammatory
WBC’s
Norepinephrine,
Epinephrine
Pro-inflammatory
Adrenaline,
Cortisol,
Vasopressin
ANS
Doctrines of Care
• Reduce the inflammatory response.
• Mobility early
– Even if on a ventilator
• Nutritional
– support early
• Ventilator weaning
• Sedation vacation
• Prevent further complications
– Law of unintended consequences.
Doctrines of Care
• Multidisciplinary Teams
– Physicians
– Nurses
– Case Manager
– Social Worker
– Respiratory Therapist
– Physical Therapist
– Nutritionist
– Pharmacy
Continuum of Care
• Palliative Care with
restoration
• LTACH
• SNF
• Hospice
• Home with Home
Health
• Home
• All of these options
need to be discussed
open and honestly with
each patient by all
members of the
Multidisciplinary team.
• Being a Patient
Advocate is knowing the
resources and options.
Conclusion
Caring for the patient with Chronic Critical
Illness is delicate and timely. These
patients and families are traumatized by
what they are facing and the fear of the
unknown road that is ahead of them.
References.
Girard K, Raffin TA. The chronically critically ill: to save or let die? Respir Care 1985;30:339–347.
Nelson, J.E., Cox, C.E., Hope, A.A., Carson, S.S. Chronic Critical Illness. American Journal of Critical Care Med. Aug.
15, 2010: 182(4): 446-454.