Critical care clinics
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Critical care clinics · Jul 2002
ReviewRehabilitation of the patient with chronic critical illness.
Patients with CCI have continuing profound medical needs, poor prognosis for significant functional recovery, and a high mortality rate. Nonetheless, some survive for months or years, but unfortunately, often with functional skills and quality of life lower than need be. Careful evaluation of each patient's medical condition and potential for functional improvement, early involvement of the rehabilitation team, prevention and treatment of medical conditions associated with prolonged bed rest and immobility, reduction of the emotional and financial burden of family members, and establishment of reasonable goals can increase self-sufficiency and quality of life regardless of discharge destination.
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The chronically critically ill (CCI) are complicated, labor-intensive, and costly patients to care for. A defined structure of care with different focuses at the beginning, middle, and end of a care episode may improve their outcomes and resource utilization. This article reviews the prediction of CCI, outlines some unifying processes of care during an episode of chronic critical illness, and explores some of the difficulties in defining consistent goals of care for this patient population.
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The neuroendocrine stress response is a dynamic process involving multiple hormonal alterations with distinct features in the acute and chronic phase of critical illness. In the initial response to an acute stress event, the anterior pituitary actively releases its hormones into the circulation while in the periphery, anabolic target organ hormones are inactivated. This response is thought to be beneficial and adaptive. ⋯ The concomitant endocrine changes in chronic critical illness may have predisposed to severe side effects of high doses of GH. In view of the significant benefits of strict glycemic control using exogenous insulin recently demonstrated in ICU patients [101], GH-induced insulin resistance and hyperglycemia may have played a role. It remains to be studied whether endocrine intervention with releasing factors such as TRH and GHRP in prolonged critical illness will accelerate recovery of patients who have entered the vicious circle of prolonged intensive care dependency.
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Critical care clinics · Jul 2002
ReviewNutrition support of the chronically critically ill patient.
Providing nutrition and metabolic support to the CCI patient is based on the rational application of scientifically derived data and clinical experience with this unique population. Much of the data presented has been extrapolated from the critically ill ICU patients and the chronically ill hospitalized or nursing home patient, as there are limited data solely based on an experience with the CCI [table: see text] patient population. The key principles are: (1) primacy of protein provision and avoidance of overfeeding energy, (2) use of combined modality (enteral, parenteral, and oral) nutrition to meet needs as required, (3) use of adjunctive agents to promote nitrogen retention when needed, and (4) recognition of and adjustment for altered nutrient requirements (Table 3).
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After weaning from PMV, patients are usually far from ready to resume normal activities. A prolonged recovery period after catastrophic illness is the rule, with multidisciplinary rehabilitation and discharge planning efforts. Following such efforts, reports of success of restorative care are institutional and population specific. ⋯ The authors are participating in a multicenter study that will yield some of these data; no doubt others will also address these questions. In the mean time, "No one in our society is willing to put Grandma out on an iceberg because she's no longer contributing. Someone needs to take care of these people" [137].