critical illness and useful objective measures

post intensive care syndrome (PICS)

direct result of critical illness OR indirect from immobility or disuse atrophy

often diagnosed late due to sedation, delirium, encephalopathy

3 domains of post intensive care syndrome (PICS)

physical

cognitive

mental / psychosocial

physical domain of PICS

ICU acquired weakness

ICU acquired neuromyopathy

critical illness polyneuropathy

pulmonary impairments

cognitive domain of PICS

memory

problem solving

attention

processing speed

mental / psychological domain of PICS

anxiety

depression

PTSD

complicated grief

symptoms of PTSD

intrusive thoughts, memories, dreams, or flashbacks

avoiding reminders of trauma

altered cognition and mood

altered reactions or level of alertness

what 3 types of weakness are associated with PICS

ICU acquired weakness

ICU acquired neuromyopathy

critical illness polyneuropathy

ICU acquired weakness

acute

symmetrical

critical illness myopathy

weakness proximal > distal

NOT caused by denervation of muscle

atrophy depends on length of illness

sensation preserved

critical illness polyneuropathy

weakness distal > proximal

variable muscle atrophy

sensory changes

causes of icu acquired neuromyopathy

metabolic, inflammatory, bioenergetic muscle derangements

impaired O2 and nutrient delivery due to microvascular dysfunction to peripheral nerves

negative variables that impacts ICU acquired neuromyopathy

sepsis

impaired respiratory function

hyperglycemia (increases oxidative stress on system)

risk factors for ICU acquired neuromyopathy

hyperglycemia

corticosteroids

MMT <80% in 3+ muscle groups / limbs

muscle atrophy

begins within hours of immobility

5% of muscle strength lost per 1 week of bedrest

elderly at higher risk due to sarcopenia and lower muscle mass

are DTRs increased or decreased with ICU acquired neuromyopathy

decreased

early interventions (first 24 hours) for neuromyopathy

early mobility

OOB

benefits of early mobility for icu acquired neuromyopathy

decreased mechanical ventilation duration

decreased LOS

maintain / regain independence with ADLs

pulmonary rehab improved 6mwt

what needs to be closely controlled and monitored in the ICU

glucose levels / glycemia

risk factors / prognosis for icu acquired neuromyopathy

P: patient - age, sex, BMI, oral frailty, comorbidities, education level

I: illness - severity, shock, inflammation, delirium

C: care - ventilation, catheter, operation, nutrition

S: stress - sound, light, positioning

ABCDEF model

a: assess, prevent, and manage pain

b: both spontaneous awakening and spontaneous breathing trials

c: choice of analgesia and sedation

d: delirium

e: early mobility and exercise

f: family engagement

what can bring on systemic inflammatory response syndrome (SIRS)

ischemia

inflammation

trauma

infection

systemic inflammatory response syndrome (SIRS)

clinical inflammatory response to nonspecific insult (infectious or non infectious)

singular organ dysfunction usually triggers it

what is required for a diagnosis of systemic inflammatory response syndrome (SIRS)

2 or more of the following

• fever >38 degrees C OR temperature <36 degrees C

• HR >90 BPM

• RR >20 breaths/min OR PaCO2 <32 mmHg

• abnormal WBC (>12,000 or <4,000)

what is usually used to confirm a diagnosis of systemic inflammatory response syndrome (SIRS)

interleukin 6 blood draw

may also use CBC, ESR, and C reactive protein

hypovalemia

BP drops during inflammation due to vasodilation

SIRS response stages

1: local cytokine production

2: cytokines released into circulation, macrophages and platelets recruited

3: excessive cytokine release leads to cascade of hormone activation, organ failure

sepsis

presence of SIRS plus a probable or confirmed infection

starts in one organ but often leads to multi organ failure

**thiamine and ascorbic acid treatment trials

severe sepsis

presence of SIRS plus probable or confirmed infection

PLUS: low SBP, low platelet count, decreased urine output, abrupt MSK change, SOB

indicates organ is failing

septic shock

having extremely low BP despite fluid replacement

increased need for vasopressors

urosepsis

systemic bacterial infection in the bloodstream

originates from urogenital organs

can be triggered or complicated by a UTI or obstruction

consider a urinalysis and CBC

PT implications for sepsis and urosepsis

can rapidly decline in status

need aggressive treatment (antibiotics and steroids)

vulnerable to multi resistant organisms like MRSA

slow rehab and potential long term organ problems

what are the most common infections that lead to sepsis or urosepsis

pneumonia

abdominal

blood

kidney

treatment for sepsis

focus on cause

central access for IV and monitoring

tight glucose control!!!!