Chronic Critical Illness After Trauma: From Description to Treatment?*
In this issue of Critical Care Medicine, Mira et al (7) describe the epidemiology of CCI in a cohort of 135 patients who had suffered a major blunt trauma with hemorrhagic shock, who had survived the first 48 hours after the incident, and who were treated in two level 1 trauma centers. Patients who were not expected to survive the first 48 hours and patients with severe brain injury were excluded. CCI was defined as organ dysfunction that lasted for 14 days or longer and requiring ICU treatment. The study was part of a much larger endeavor aimed at deciphering the relationship between genomic and immune responses and clinical outcome after trauma and burns, known as the “Glue Grant Experience” (8). Mira et al (7) found that 19% of patients developed CCI. Risk factors for developing CCI were older age and markers of increased illness severity at initiation of intensive treatment: Denver multiple organ failure score, the amount of blood transfused, and the lowest blood pressure, whereas sex, body mass index, number of comorbidities, and mechanism or severity of the injury (as measured by Injury Severity Score) were not. Patients with CCI fared much worse than patients who did not develop CCI: mortality was higher both ICU and hospital length of stay were longer and they had more complications. More than half of patients with CCI either died or had a poor discharge disposition. These findings are consistent with what we already know about CCI and may appear almost self-evident: sicker patients are being treated longer in the ICU and have a worse outcome. Surprisingly, although the general health domain of the 36-Item Short Form Survey (SF-36) scores was lower at 4 months in CCI patients compared to those with rapid recovery, all other domains were comparable in both groups. Most follow-up reports use 6 months as a follow-up time point, and it would be interesting to know whether the significant difference in this domain has disappeared by then.