Resp Care
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Past research in chronic critical illness has been effective in defining the population and identifying unique aspects of their outcomes and resource needs, but there has been little research focused on interventions to improve outcomes. This review discusses some research priorities that could have immediate impact on patient outcomes. General topics include prevention or limiting the incidence of chronic critical illness; specific topics related to patient management, such as interventions for weaning, rehabilitation, nutrition or infections; and methods to enhance communication and end-of-life care. In addition to specific patient management interventions, further comparative effectiveness research on care settings is indicated, considering the expected growth in the patient population and the substantial resource needs.
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Critically ill patients frequently experience acute brain dysfunction in the form of coma or delirium, both of which are common during acute and chronic critical illness (CCI). These manifestations of brain dysfunction are associated with numerous adverse outcomes during acute critical illness, including prolonged hospitalization, increased healthcare costs, and increased mortality. The prognosis of CCI patients with coma or delirium has not yet been thoroughly studied, but preliminary studies suggest this population is at high risk for detrimental outcomes associated with acute brain dysfunction. ⋯ Interventions directed at reducing the burden of brain dysfunction during critical illness have shown promise in studies of patients with acute critical illness, but these therapies have yet to be studied during CCI. Thus, multicenter randomized trials are needed to determine which interventions are most effective for such patients. Until these data are available, management strategies that have been proven beneficial during acute critical illness-such as reduction of sedative exposure, especially to benzodiazepines, and early use of physical and occupational therapy-should be employed during the treatment of patients with CCI.
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Palliative care is an essential component of comprehensive care for all patients with chronic critical illness, including those receiving restorative or life-sustaining therapies. Core elements include alleviation of symptom distress, communication about care goals, alignment of treatment with the patient's values and preferences, transitional planning, and family support. Here we address strategies for assessment and management of symptoms, including pain, dyspnea, and depression, and for assisting patients to communicate while endotracheally intubated. ⋯ Challenges for supporting families and planning for transitions between care settings are identified, while the value of interdisciplinary input is emphasized. We review "consultative" and "integrative" models for integrating palliative care and restorative critical care. Finally, we highlight key ethical issues that arise in the care of chronically critically ill patients and their families.
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Whether defined as chronically critically ill, long-term mechanical ventilator dependent (or otherwise chronically medically supported), or medically fragile, a population of infants and children with chronic illness clearly exists. Infants and children with chronic healthcare needs are at an increased risk for physical, developmental, behavioral, and/or emotional conditions and generally require healthcare services of a type or amount beyond that of a general pediatric or adult population. ⋯ Attention will be paid to defining the population, describing trends over time, reviewing their special needs, and discussing outcomes. Increased focus and an increasing quantity of resources for this subgroup of infants and children are needed, as the number of such pediatric patients continues to grow.
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Chronic critical illness (CCI) is syndrome of neuromuscular weakness, brain dysfunction, malnutrition, endocrinopathies, and symptom distress. Two conceptual themes may be useful in discussing CCI. The first is a clinical roadmap in which a patient suffers an acute critical illness, survives the initial insult, but yet is unable to be liberated from the ventilator. ⋯ Given the association between common CCI antecedents and inflammation, attempts to control and balance the pro-inflammatory and anti-inflammatory mediators should begin as early as possible and continue throughout the ICU stay. Since surrogate measures such as biomarkers often fail to predict the effect of interventions, the focus should be on the outcomes patients experience. As of now, providing evidence-based, high quality ICU management of patients at risk for CCI appears to be the best strategy of care.