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ICU-Acquired Weakness and Recovery From Critical Illness
ICU-Acquired Weakness and Recovery From Critical Illness
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The case description below highlights issues raised in an upcoming Critical Care Medicine article. A
77-year-old man is on mechanical ventilation in the ICU after an emergency colon resection,
complicated by septic shock and acute liver failure. Since it appears his stay in the ICU will be
prolonged, what measures would you take to optimize his long-term recovery?
Participate in the poll and share your comments. The editors recommendations and the
related review article will appear on April 24.
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Presentation of Case
A well-nourished 77-year-old man whose medical history includes treated hypertension and
hypercholesterolemia, previous heavy alcohol intake, and mild cognitive impairment is admitted
to the intensive care unit (ICU) of a university hospital from the operating room after a
Hartmanns procedure (resection of the rectosigmoid colon with closure of the rectal stump and
formation of an end colostomy) performed for fecal peritonitis due to a perforated sigmoid colon.
On arrival in the ICU, he was in septic shock. He is undergoing mechanical ventilation with the
use of a low-tidal-volume protocol with positive end-expiratory pressure (PEEP). His arterial
blood pressure is supported with a norepinephrine infusion. Analgesia is provided by a
continuous morphine infusion. Enteral nutrition was started on the day after ICU admission, and
target intake was achieved on day 6. Parenteral nutrition was not used. (In the previous
installment of this case, there were 2906 votes on strategies for feeding this critically ill patient.
A majority of respondents [53%] favored initiating enteral nutrition within 24 to 48 hours after
ICU admission and then starting parenteral nutrition on day 7 if the caloric target was not being
met. Another 30% favored initiating parenteral nutrition as soon as possible after the patients
arrival in the ICU and then starting enteral nutrition once bowel sounds return, whereas 11%
favored awaiting the return of bowel sounds and then initiating enteral nutrition. Only 4%
favored initiating total parenteral nutrition as soon as possible after the patients arrival in the
ICU.)
Question
Since it is likely that this patient will have a prolonged stay in the ICU, what measures would
you take to optimize his long-term recovery? Participate in the poll and, if you like, submit a
comment supporting your choice. The editors recommendations will appear here, along with a
link to the related review article, on April 24.
61 Reader's Comments
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RHIA Professional
For this case of LTC of Critical illness it is important to determine and meet goals of
care, treatment plans and end-of-life plans. After the patient show hemodynamic stability,
progress to oral feedings from enteral feedings, elevate HOB if not contraindicated. Use
weaning protocols and begin P.T. as soon as possible to limit ICU-related weakness. This
patient will require continued monitoring.
as a surgeon , i try to stabilize the patient first with checking and correcting fluid,
electrolytes, and acid-base balance with giving him fluid with controling CVP through
the right sided subclavian central catheterization. keeping it in the normal range 12-15 cm
-h2o.giving him antibiotics, broad spectum , covering also anaerobics.. checking
coagulation profile and giving him heparin for venothrombosis prophylaxis.covering him
with warm blanket to avoid hypothermia and correcting acidosis( metabolic ).waiting for
ileus resolution then if there is no abdominal distention and flatus passed through the
stomy give him enteral nutrition as tolerated.considering checking CRP and ESR may
help to think of any collection in the abdominal cavity.. chest physiotherapy is begun the
next day.i also check serum amylase and lipase in this fellow as a baseline. intake , output
should be regularly charted and checked very carefully.
NO HOLIDAYS
It is important to realize based upon the research Dr. Ely and colleagues with the
Vanderbilt Med Center ICU Delirium & Cognitive Impairment team that this as much or
more about brain injury as it is about the damage caused to any other organ or system.
This is not conjectural. They have learned there is a very specific brain loci of damage
which accompanies the majority of those whose clinical picture included ICU delirium.
With that in mind, I think it is important to realize that even after a patient has apparently
emerged from their state of delirium it remains highly likely that ICU delirium remains in
play and must continue to be managed through proper attention to titration of pain and
benzodiazapine levels. My own experience is instructive. Although I was no longer
acting "crazy" I have no memory whatsoever of having been spoken with regarding the
need for emergent surgery much less that I was asked to and did sign the consent form.
Control ICU delirium and cases like these will be minimized.
Most get inadequate nutrition support during the first couple of weeks of ICU care. After
10 days repletion and adequate protein be the focus with PT to help turn it back into
muscle.
Strict glycemic control Blood cultures Check acid base and electrolyte status and
urea/creat Avoid aspiration pneumonia Titrate the dose of morphine Look for signs of
DIC Daily intake and output monitoring Start enteral feeding once bowel sounds return
Avoid nephrotoxic drugs
ICU-Acquired weakness.
Decrease risk factor for the developement of ICU-acquired weakness and early active-
passive mobilization.
remenber early mobilization and use of splits , the blood thinners are ok and attemp to
stand him in a bed try to return to circadian cycle day and nights
Alcohol
deconditioning
This gentleman is heading down the road towards becoming part of the cohort now
discarded from the ICU to an LTAC as "chronically critically ill." No where in the story
has there been any discussion about what this guy would want in this situation, but many
of the suggestions of trach/PEG, etc. assume that he would be okay with a 6 month to 1
year recovery in the best case from something like this. If he has another major
complication, then these issues become more and more pertinent in the overall prognosis
and decision making.
He's already in trouble given the scenario. He needs to be fed, and if his gut is not
working, he needs TPN/PPN. He is already catabolic, so he needs fairly high protein if
his kidneys will tolerate it. Assessment of lean muscle mass is still in evolution, but it
might be helpful. Many of these patients come in with low-grade malnutrition and it only
gets worse. He needs to get exercise. If he's awake/alert enough to cooperate (see earlier
comments about sedation), get him out of bed and walk him on a portable ventilator. Yes,
it's labor intensive for the staff, but it really helps both physically and mentally for patient
and family. Otherwise, passive exercises in bed (get the family involved), progressing to
more active exercises.
Diagnosis
My first suggestion would be to administer Colloidal Silver in one way or another - to the
equivalent and minimum of 4 oz. per day orally - 1 oz. 4 times a day, or according to the
need, especially in this critical stage, and especially if any signs of infection are noticed.
Secondly, sufficient fluids must pass through his system for the removal of dead cell
debris via the bloodstream, kidneys and urinary tract - In a normal situation, anywhere
from 30% to approx. 40% of his body-weight (lbs.) in ounces per day. Thirdly, as the
fluids are administered, his blood sugars must be monitored and maintained at the best
level for optimum healing to take place, and the most accurate method of determining
one's blood sugars is by an analysis of the urine with a Refractometer. For the best chance
of healing, the urinary Brix reading should be from 1.0 to 2.0 - definitely no lower than
1.0. And 4th, monitor his urinary pH. The optimum healing numbers for the pH are 6.2 -
6.8. Various calciums, foods, juices, vitamins, etc. can be used to adjust the body's pH
especially with the calciums that are lacking according to the urine and saliva pH's.
Early physiotherapy
Physiotherapy should be implemented in day one with some strategies as: - Passive range
of motion and eletrical muscle stimulation while he is still sedated. - Early mobilization
as soon as possible (active exercises, sitting on edge of bed and outside bed, standing and
ambulating).
What is being done about the sepsis? Are the SSC guidelines for the management of
severe sepsis and septic shock being followed?
Early consultation from the speech pathologist to address communication and alleviate
anxiety and depression. Early tracheostomy to facilitate weaning, minimize
complications and damage to vocal tract, facilitate early communication and oral feeding.
Early cuff deflation and in-line speaking valve trials to restore normal physiology and
exhalation through upper airway, to prevent atrophy of oral/pharyngeal/laryngeal
muscles, to restore protective glottic closure reflex for swallow, to restore cough strength
and secretion management.