The long-term ICU Patient

OVERVIEW

  • increased frequency with older, more deconditioned patients presenting to ICU
  • this patient are high risk

CARE IN ICU

Airway

  • tracheostomy management (insertion, weaning, decannulation, complications)

Breathing

  • slow respiratory weaning techniques
  • sputum management
  • humidification

Circulation

  • volume status assessment and management
  • arrhythmias: AF
  • long term cardiac function optimisation

Disability + Neurological

  • delirium surveillance
  • optimize communication (writing boards, speaking valves)
  • high incidence of depression
  • glucose control (adequate not tight)
  • critical illness weakness
  • physio

Exposure + Infection

  • nosocomial surveillance and prevention
  • care with possible selection of multiresistant organisms

Feeding

  • nutrition
  • fluid balance
  • fine bore N/G tube

Gastrointestinal

  • stress ulcer prophylaxis (controversial)
  • enteral nutrition establishment

Lines

– minimization of lines
– minimization of unnecessary blood tests

Labs

  • see above
  • twice weekly

Medications

  • review with attempts to minimize
  • convert all IV medications to oral formulations

FASTHUG

  • Feeding
  • Analgesia
  • Sedation
  • Thromboprophylaxis
  • Head elevation
  • Ulcer prevention
  • Glucose control

Family

  • regular up dates
  • clear communications
  • multi-disciplinary team involvement

CARE IN HOSPITAL BUT OUTSIDE ICU

  • high risk patients
  • high readmission rate
  • should not be discharged out of hours
  • good careful handover
  • tracheostomy support
  • close liaison with ward teams
  • rehabilitation

POST ICU ISSUES

  • at risk of many complications
  • pressure areas
  • weakness
  • scars
  • fistulae
  • pain
  • sleep disturbance
  • cognitive dysfunction
  • psychological sequelae: PTSD
  • renal injury
  • ischaemic heart disease
  • DVT

-> most data suggesting: increase mortality, decreased level of functioning out to 5 years.
-> some data suggesting that good functional outcome can be achieved at 6 months (Dennis, CCR, 2011)

OUTCOME ASSESSMENT

  • follow up clinics
  • European QL
  • Adjusted Life Years
  • SF-36
  • Glasgow outcome score

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the  Clinician Educator Incubator programme, and a CICM First Part Examiner.

He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.

His one great achievement is being the father of three amazing children.

On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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