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 in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

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

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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