Chronic Critical Illness After Trauma: From Description to Treatment?*

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The term “chronic critical illness (CCI)” refers to intensive care patients who have successfully survived an initial insult but who do not recover readily enough to be liberated from intensive care (1–4). In relevant literature, several overlapping definitions are used for CCI all reflecting the failure to discharge the patient from intensive care within a few weeks. For patient and kin, CCI results in disappointment due to the poor outcome after the initial success of survival by virtue of intensive therapy. For critical care services, CCI amounts to a high resource utilization, spending lots of energy and money on patients, many of whom will eventually die or spend their final days in nursing homes (5). Even if only 5% of patients develop CCI, they consume a considerable share of resources: five patients spending 100 days in the ICU use as many resources as one hundred patients being treated for 5 days each. It is difficult to predict at ICU admission which patient will develop CCI, although generally speaking, patients who progress to CCI are older and sicker as compared to patients who recover more rapidly. It is also difficult in patients with CCI to discern between those who will eventually die even after prolonged intensive care treatment and those who will ultimately recover. Simply looking at the time already spent in the ICU is not helpful in discerning futility from the likelihood of eventual recovery as illustrated by a study which showed that even after 60 days of intensive treatment, only 44% of patients were alive 1 year later (6).
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.
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