One growing problem within modern medicine is success. Little by little, physicians have developed ways to help patients get through challenges that once seemed insurmountable. Surviving certain forms of critical illness has become almost routine—but hardly quick, or easy, or without lasting consequences.
“We don’t see a lot of simple, straightforward patients in our intensive care unit,” said medical intensivist J.P. Kress, MD, professor of medicine at the University of Chicago. “We rarely see the typical ICU patients, those who were reasonably healthy until something bad hit them.” Instead, the ICUs at the medical center tend to draw patients with chronic medical illness, such as stage-IV lung cancer, who were already damaged by longstanding disease—and then something catastrophic happened.“Our job is to regain control, fix what we can and then get them out of intensive care in a reasonable amount of time, without the damage that we now know comes with prolonged sedation and profound inactivity.”
This persistent devotion to limiting sedation and inactivity, by waking patients up, daily if possible, and getting them out of bed, led the New England Journal of Medicine to invite Kress and his colleague Jesse Hall, MD, section chief of pulmonary and critical care medicine at the University, to write a review article on the topic. It was published 24 April 2014.
Their article, “ICU-Acquired Weakness and Recovery from Critical Illness,” focuses on the consequences, such as loss of cognitive skills and muscle strength, caused by long stays in intensive care, especially when that care includes deep sedation and protracted immobility.
Hall, Kress and colleagues have been studying this issue for decades. In 2000 they published a high-profile paper, also in the NEJM, about daily awakenings for ICU patients, what they call a sedation vacation. They showed that by taking mechanically ventilated patients in intensive care off of tranquilizing medications for a short time each day, they were able to reduce the duration of ventilation and cut ICU stays by one-third.
Not everyone initially approved. Some were concerned that waking patients each day could trigger dread and anxiety, not unlike traumatic stress disorder. But patients who were awakened actually did better. They had a fewer mood disorders and little anxiety. They had less difficulty concentrating, shortness of temper and frightening memories. For patients in intensive care, “maintaining some awareness of reality,” Kress told a New York Times reporter, “is better for your psyche.”
The next step was to see if sedated and ventilated patients, with considerable help from nurses and physical and occupational therapists, could sit up in bed, or in a chair, or even walk, despite their life-support lines and tubes. That study, published in The Lancet in 2009, found that mobilized patients were nearly two times as likely to regain independent functional status by the time of hospital discharge as those who were not woken up and—at some level—exercised. Patients in the intervention group also had less delirium and more ventilator-free days over the next month.
This strategy of “whole-body rehabilitation—consisting of interruption of sedation and physical and occupational therapy in the earliest days of critical illness—was safe and well tolerated, and resulted in better functional outcomes at hospital discharge, a shorter duration of delirium, and more ventilator-free days compared with standard care,” the authors concluded.
The 2014 review article pulls together these and many other studies and summarizes the literature on ICU-acquired weakness. It describes current thinking about the causes and mechanisms that result in such profound weakness. It maps out a systematic way to diagnose and evaluate such weakness in critically ill patients, an algorithm with 20 interconnected boxes recommending tests, interventions or other next steps.
The final quarter of the article, though, focuses on the core problem of success, how to minimize the neuromuscular and neuropsychological consequences of surviving formerly deadly illnesses. These are not rare or trivial problems. Recovery is often slow and incomplete. In some patients, muscle weakness and functional impairment remain common a year after discharge and in many cases recovery remains “far from complete” five years later.
“The focus on rehabilitation of critically ill patients should begin in the ICU and continue all the way to recovery at home,” Kress and Hall stress. The central goals of care should include “optimizing early physical activity in spite of the severity of illness,” they insist. This means minimizing sedation and assembling a wide range of caregivers who can get patients, even those who remain critically ill, up and out of bed.
Although this is not a traditional approach, they add, the early mobilization, which seemed a bit radical a decade ago, has since become “an evidence-based strategy to reduce the deconditioning and dysfunction so commonly seen in survivors of critical illness.”
Kress J.P. & Hall J.B. (2014). ICU-Acquired Weakness and Recovery from Critical Illness, New England Journal of Medicine, 370 (17) 1626-1635. DOI: 10.1056/NEJMra1209390