Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1134_Библиотеки_им_академика_М_И_Перельмана.pdf
494
S.M. Briggs
13. Macintyre A, Kramer E, Petinaux B, et al. Extreme measures: fi eld
amputation on the living and dismemberment of the deceased to
extricate individuals trapped in collapses structures. Disaster Med
Publ Health Prep. 2012;6(4):425–35.
14. Raines A, Lees J, et al. Field amputation: response planning and
legal considerations inspired by three separate amputations. Am
J Disaster Med. 2014;9(1):53–7.
15. Sechriest VF, Wing V, et al. Healthcare delivery aboard US navy
hospital ships following earthquake disasters: implications for
future disaster relief missions. Am J Disaster Med. 2012;7(4):
281–94.
16. Joint Committee to Create a National Policy to Enhance
Survivability from Mass Casualty Shooting Events. Improving survival from active shooter events: the Hartford consensus. Bull Am
Coll Surg. 2013;98(6):14–6.
17. Kearns R, Skarote MB, Peterson J, et al. Deployable, portable and
temporary hospitals; one state’s experiences through the years. Am
J Disaster Med. 2014;9(3):195–207.
18. Comstock S, Pannel D, Talbot M, et al. Spinal injuries after improvised explosive device incidents: implications for tactical combat
casualty care. J Trauma. 2011;71(5 Suppl 1):S413–7.
19. Lin G, Lavon H, Gelfond R, et al. Hard times call for creative solutions: medical improvisations at the Israel Defense Forces Field
Hospital in Haiti. Am J Disaster Med. 2010;5(3):188–92.
20. Kragh J, Walters T, Baer D, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg.
2009;249:1–7.
21. Latifi R, Tiley E. Telemedicine for disaster management: can it
transform chaos into an organized, structure care from the distance.
Am J Dis Med. 2014;9(1):25–37.
Postoperative Complications Following Surgery Abroad
Nicole Lucas and William A. Walters
4 4
Introduction
Caring for another surgeon’s complication can be a common,
albeit unpleasant, part of any surgical practice in a tertiary
care facility. It comes with the territory and can defi ne key
differences between academic and community practice.
Typically, the patient was cared for in a modern hospital, by
a surgeon that was appropriately trained, equipped with
modern and sterile equipment, and assisted by competent
nursing professionals. In essence, the presenting complication could just as easily have developed in any hospital, and
the care plan is understandable and predictable.
As societies broaden their reach, and an individual patient
is able to avail themselves of unprecedented opportunities
for global travel, the issue of surgical complications takes on
a different light. With increasing frequency, patients are presenting to tertiary care medical centers with previously undiagnosed or untreated postoperative complications after either
elective surgical care abroad or emergency surgery in an austere environment following a natural or man-made disaster.
In either case, the surgeon is left with little written accounting of the surgical procedure, postoperative course, or rehabilitation. Furthermore, the patient’s condition may be
directly related to the geographic location of the fi rst hospital
or the process of travel itself.
Elective Surgery Abroad
Elective surgery abroad, often referred to as “medical tourism,” represents a recent development in healthcare economics, involving purposeful travel of patients to a nation other
than their own for the expressed purpose of receiving care
that is either unavailable, prohibitively expensive, or illegal
N. Lucas , BS • W. A. Walters , MD (*)
U.S. Department of State , Offi ce of Medical Services ,
Washington , DC 20037 , USA
walterswa2@state.gov
e-mail:
in their own country. According to Patients Beyond Borders,
a consumer medical tourism resource, around 11 million
patients go abroad for medical treatment every year. Although
these numbers vary, the organization believes the market size
is an estimated US $38.5–55.0 billion, with the average
patient spending $3500–5000 per visit [
data, the cost of individual procedures has been an estimated
20–80 % lower in less developed countries compared to a
private hospital in the United States [ 2 , 3 ]. Furthermore, the
medical tourism market is only expected to grow, as healthcare shortages and costs to patients increase in western countries, and surgical technology costs decrease to an affordable
level in less developed countries. Although millions of
Americans are now newly enrolled into health insurance
under the Affordable Care Act, an estimated 71 % of the new
insurance arises through Medicaid [ 4 ]. And, with 55 % of
American doctors already refusing new Medicaid patients,
according to a 2014 Merritt Hawkins study by Miller and
colleagues [ 5 ], the American public is still not immune to the
pressures of healthcare austerity.
1 ]. Reviewing 2008
An Unregulated Industry
Marketing of surgical services overseas is regulated at the host
nation level, where legal restrictions regarding medical practice and quality of care may differ greatly from the patient’s
expectations. While no registry or formal means of tracking
patients has been established, published studies show a signifi cant percentage of these patients seek bariatric, dental, and
cosmetic surgery due to cost savings. Many also have a specifi c predilection toward transplant surgery, driven by the
availability of donor organs. Because quality of care varies
greatly by institution, it is diffi cult to make meaningful generalizations about risks outside the United States [ 6 ]. Information
asymmetries are particularly pronounced by a lack of comparative quality and safety data, reduced knowledge of infection rates for overseas institutions, and insuffi cient reporting
of adverse events [
7 ]. The World Health Organization issued a
© Springer International Publishing Switzerland 2016
N.D. Martin, L.J. Kaplan (eds.), Principles of Adult Surgical Critical Care, DOI 10.1007/978-3-319-33341-0_44
495
496
N. Lucas and W.A. Walters
2014 report on antimicrobial resistance, noting that very high
rates of resistance for common bacteria have been recorded in
all regions. Overall, surveillance of resistance is neither coordinated nor harmonized [ 8 ], but must be considered carefully
by the surgeon managing an imported surgical catastrophe.
Just as there is no registry of patients that seek medical care
abroad, there are no international standards that tie to outcome
measures for hospitals catering to the medical tourism market.
Several international organizations are available to accredit
hospitals in foreign countries, each with their own methods and
standards, but given the migratory nature of the medical tourist,
this specifi c patient population is almost universally lost to
follow-up. Overall, little is known about the relative clinical
outcomes for particular treatments, institutions, clinicians, and
localities associated with medical tourism, partly because follow-up is rare once patients return to their home countries after
a procedure [ 7 ]. Overall, this lack of information obstructs a
patient’s ability to make informed, evidence-based judgments
about the quality of care and safety in medical travel [
8 ].
Nosocomial and Travel-Related Postoperative Infection
Postoperative infections are not limited to hospital- acquired
pathogens. The transit involved with medical tourism may
also put patients at a greater risk of infection because passengers are typically confi ned to close quarters for many hours
when using commercial aircrafts [
veillance study from 2010, the extended- spectrum beta-lactamase colonization rate in traveling Australians increased from
7.8 % pretravel to 49 % posttravel, with resistant E. coli iso-
lated from 50 to 79 % of travelers to Asia (excluding Japan),
South America, the Middle East, and Africa. At 6 months
posttravel, 18–24 % remained colonized [ 13 ]. This demon-
strates that at any point in the circular migration of patients
traveling for medical care, microbes may also travel from one
location where they constitute a harmless bacteria, or at least a
known and treatable infection, to another where they are
unknown, making diagnosis and treatment much more problematic [
erative infection do well to discuss the case early with
infectious disease and pathology colleagues to provide suffi ciently broad consideration during the laboratory workup.
12 ]. Therefore, surgeons treating an imported postop-
12 ]. In an interesting sur-
Transplant Tourism
Postoperative infection is an ever-present risk that, in the
United States and other highly developed healthcare systems, involves signifi cant investment in broad reaching systems within each hospital. From dedicated personnel for
surveillance, materials and supplies at each bedside to reduce
transmission, and rigid inspection criteria tied to third-party
reimbursements, great effort is paid to reducing the fi nancial
burden of postoperative care. Lacking the same focus and
resources, the prevalence of healthcare-associated infections
in developing countries is substantially higher than in Europe
and the United States. Many countries with robust medical
tourism programs have high background rates of tuberculosis, antibiotic resistance, hepatitis B, hepatitis C, and human
immunodefi ciency virus (HIV) [
showed that intensive care units in developing nations had
infection rates at least three times higher than those reported
in the United States. Surgical site infection rates were also
comparatively increased (5.6 vs. 1.6–2.9 per 100 surgical
procedures) [
ism programs lie in tropical and subtropical regions where
malaria, dengue fever, enteric fever, and other endemic
infections exist [ 9 ]. And, although blood and blood products
used in hospitals certifi ed by International Joint Commission
(IJC) require screening for common blood-borne pathogens,
they do not necessarily require screening for these regionspecifi c agents. As a result, dengue and West Nile viruses,
for example, which cause rare infections after transfusion,
are not a part of routine screening in most countries and have
a higher chance at being transmitted [
10 ]. Many countries with robust medical tour-
9 ].A recent meta-analysis
11 ].
Perhaps the most popular and most risky procedures sought
by consumers in medical tourism involve solid organ transplants. In 2007, the World Health Organization estimated
that 10 % of organ transplants worldwide are the result of
transplant tourism [ 14 ], due in part to the practice of solid
organ sales and the relative affordability of the surgery itself.
In one study in the Philippines, upward of 3 % of the population in a single community had sold a kidney for transplant
[ 15 ]. However, evidence again suggests increased complica-
tion rates. In a 2009 meta-analysis, patients that travel internationally in order to receive their transplant had a lower
1-year graft and patient survival rate compared to those
domestic kidney transplant recipients described by United
Network for Organ Sharing (UNOS) [
plant tourists had an increased requirement for postoperative
surgical intervention and were more likely than domestic
kidney transplant recipients to develop cytomegalovirus
(12 %), hepatitis B virus (7.1 %), HIV (4.1 %), and wound
infections (8.6 %) [
University of Minnesota Medical Center or Hennepin County
Medical Center after undergoing kidney transplantation
overseas concluded that there was inadequate communication of information concerning immunosuppressive regimens and preoperative information. In the majority of cases,
vital information on induction therapy, immunosuppression,
and posttransplant course were missing. In three cases within
the study period for this single center, postoperative patients
were sent back to the United States in the midst of a crisis
(active severe wound infection, seizure, and acute rejection),
17 ]. A 2006 study of patients evaluated at
16 ]. In addition, trans-
44 Postoperative Complications Following Surgery Abroad
497
and in all of these situations, documentation of the posttransplant course was lacking [
18 ].
Cosmetic Surgery
Based on available data and marketing efforts by international
medical tourism “hubs,” elective cosmetic and aesthetic surgery represents the majority of the medical tourist surgical
caseload. A 2007 national study conducted by the Australian
Society of Plastic Surgeons evaluated female patients returning
from Asia after surgery, a majority of which underwent breast
enlargements, breast reductions, or facelifts. Of the 68 surgeons surveyed, 40 (59 %) reported seeing patients with complications or poor results, and 15 (22 %) reported treating more
than one patient that had traveled abroad for their cosmetic procedure. The majority of procedures were reportedly performed
in Thailand, followed by Malaysia [ 19 , 20 ]. In an audit of the
pan-Thames region of the UK, 60 % of National Health
Services (NHS) consultants in plastic surgery units had seen
complications of returning patients after completed procedures
abroad, including abdominoplasty, breast augmentation, and
breast reduction. The majority of these cases (66 %) were
emergencies that required inpatient admission [ 21 ]. In a survey
of the British Association of Plastic, Reconstructive and
Aesthetic Surgeons members, 37 % of consultants report having seen patients in the National Health System with complications arising from overseas cosmetic surgery. The most popular
procedures included breast augmentation, abdominoplasty,
breast reduction, and face/neck lift. The majority (88 %) were
referred to these plastic surgeons by primary care and emergency department colleagues and required treatment in an outpatient setting (i.e., wound management) or elective surgical
revision for cosmetic reasons. Twenty-fi ve percent of patients
required emergency surgery [ 22 ]. Finally, in a 2011 survey of
the American Society of Plastic Surgeons (ASPS), 83.9 % of
surgeons reported treating patients with complications who had
undergone cosmetic procedures abroad by noncore practitioners. A majority of the noncore providers performing procedures abroad were otolaryngologists, but also included general
surgeons, oral surgeons, OB-GYNs, and ophthalmologists.
The largest percentage of reported complications (31 %) in this
study were postoperative infections, followed by dehiscence,
contour abnormality, and hematoma [ 23 ].
Surgical Complications in the Context of Disaster Medicine
In contrast to medical tourism, where procedures are planned
and researched by patients in advance, surgical resuscitation
following critical injury abroad occurs in the most remote
locations, where the untouched beauty of nature is usually
accompanied by an undeveloped or completely absent medical infrastructure. In a retrospective database review of
American citizen deaths worldwide from October 2002
through June 2012, authors found the total number of
Americans traveling abroad annually was approximately
58.7 million, with the majority traveling to Mexico, Canada,
the United Kingdom, France, and Italy. Only one accidental
death of an American occurred during the 10-year study
period in those highly traveled areas. In travelers visiting less
common destinations, however, the story is quite different.
There were 7,963 American citizen nonnatural deaths abroad
during this study period, and of these 163 (2 %) were due to
disaster-related deaths. These deaths occurred as a result of
19 disasters in 15 countries, with the only disasters causing
greater than 2 deaths being the 2010 earthquake in Haiti
(resulting in 121 deaths) and the 2004 tsunami in Thailand
(causing 22 fatalities) [ 24 ].
In a 2013 meta-analysis focusing on acute traumatic injuries requiring surgical intervention following earthquakes
abroad, Missair and coworkers found that major earthquakes
result in the highest casualty rates, between 1 and 8 % of the
at-risk population [
of earthquake-related injuries requiring urgent surgical intervention involved survivors with limb trauma and survivable
traumatic injuries including bone fractures, soft tissue lacerations, and crush injuries to various parts of the body. In
humanitarian disaster and confl ict, amputation is often hastily performed as a way of removing signifi cant amounts of
damaged tissue and saving a life, without consideration for
more conservative techniques. This strategy requires multiple surgical revisions and results in complicated postoperative management and prolonged rehabilitation periods for
patients.
The Haitian earthquake of 2010 provides a good example
of surgical management following a large-scale disaster that
destroys what little medical infrastructure may exist. Many
patients received amputations as a primary intervention for
complex severe wounds and fractures which could potentially have been salvaged. Amputations as secondary treatment for infected wounds and compartment syndromes were
also reported in high numbers even though this is not the
standard of care. Signifi cant volumes of guillotine amputations were performed as a “lifesaving intervention” or when
technical expertise was limited, subsequently requiring revision at higher levels. These patients’ rehabilitation potential
was negatively affected by poor surgical indication, timing,
and technique [ 26 ]. In the end, Haiti’s earthquake left
approximately 1,500 amputation survivors relying on a
healthcare system whose baseline, pre-earthquake surgical,
anesthesia, rehabilitation, and prosthetic services were
already severely limited [ 27 ]. Many survivors were evacu-
ated to the United States on humanitarian grounds for continued treatment.
25 ]. Though many injuries are fatal, 69 %
498
N. Lucas and W.A. Walters
Surgical Infections in Disaster Response
Emergency surgery following a natural or large-scale manmade disaster safely assumes that the deliberate care and processes associated with modern surgical technique break down,
if only for the sake of expediency in saving the greatest number of lives. Given unhygienic conditions, gross wound contamination, and delayed presentation of patients following a
building collapse, catastrophic bombing, or fl ood, it is no surprise that surgical infections are common causes for operation
in low- and middle-income countries, particularly during a
crisis. Infections, in general, require greater than expected surgical resources given the frequent need for serial operations,
especially in these areas with limited resources. Because survival and quality of life after severe surgical infection depends
on prompt resuscitation, antibiotics, and operative intervention, a large proportion of individuals with surgical infections
may be left with disability or not survive. Subsequently, the
surgical disease burden, condition for condition, is signifi cantly greater in poorer countries than the rest of the world,
and early efforts to evacuate patients to western medical facilities should be expected in an effort to spread the load across a
wider and better prepared healthcare base.
In a review of procedures performed in operating rooms
managed by Medecins Sans Frontieres/Doctors Without
Borders–Operations Centre Brussels from July 2008 through
June 2014, investigators found that operations for skin and soft
tissue infections were the most common surgical infection
(64 %), followed by intra-abdominal (26 %), orthopedic (6 %),
and tropical infections (3 %). Return trips to the operating
room for serial washouts, debridement, and “second looks”
were more common after procedures for orthopedic (38 %)
and skin and soft tissue infections (33 %) than for intraabdominal infections. In reviewing resource utilization patterns, it is clear that the pattern of operations for infections is
related to nature of the crisis. Resources necessary for the
treatment of skin and soft tissue infections (e.g., dressing supplies) are disproportionately higher during natural disasters,
while resources necessary for intra-abdominal infections (e.g.,
closed suction drains, temporary abdominal closure systems)
are needed more during hospital support missions. Lastly,
resources necessary for the management of orthopedic infections (e.g., surgical sepsis care, ultrasound- guided drainage
procedures) are critical during support to areas of armed confl ict [ 28 , 29 ].
Strategies in Patient Management
Assumptions remain the greatest barrier to management of a
patient treated abroad that presents with a postoperative
complication. When treating patients in one’s own city or
country, it is said that “when you hear hoof beats, think
horses.” But, the astute clinician treating an imported postoperative complication must fi rst ask to which ground he has
placed his ear before defi ning the probability of horses versus zebras.
The investigation starts with a carefully obtained history,
developing a comprehensive picture of the patient’s preoperative state of health. Then consider the location and setting of
the surgical procedure. Early consultation with infectious disease colleagues with specifi c knowledge of tropical disease is
essential, and frank collaboration with laboratory medicine
colleagues will yield early benefi ts in identifying unusual
pathogens. Early imaging is critical in identifying deep tissue
abscesses and retained instruments or materials as the source
of postoperative infection. For the critically ill patient that is
unable to provide a detailed history, evaluation of the location
and type of surgical wound is critical and must be compared
to both modern surgical approaches and outdated approaches
that may still be in use in less developed countries.
Perioperative management of the critically ill medical
tourist may require a more protracted period of empirical
therapy, allowing for offsite testing of samples for unusual or
exotic pathogens. Early consideration must be given to
fungemia, parasitemia, and viral etiologies that are typically
prevented in western surgical practice. Finally, it is important
to account for the psychological impact of a debilitating or
disfi guring postoperative complication, ranging from regret
in having accepted the risk of an elective procedure abroad to
frank post-traumatic stress disorder related to the disastrous
etiology for their original injury.
References
1. Nelson R. Infectious risks of medical tourism. Lancet Infect Dis.
2014;8(14):680–1.
2. Reed CM. Medical tourism. Med Clin N Am.
2008;92(6):1433–46.
3. Kher U. Outsourcing your heart. Time Mag 2006.
2006;167(22):44–7.
4. Haislmaier E, Gonshorowski D. Obamacare’s enrollment increase:
mainly due to medicaid expansion. The Backgrounder 2014; 2967.
5. Miller P. Physician appointment wait times and medicaid and medi-
care acceptance rates. Irving, Texas. Merritt Hawkins. 2014.
6. Rosenthal VD, Richtmann R, Singh S, et al. International
Nosocomial Infection Control Consortium. Surgical site infections,
International Nosocomial Infection Control Consortium (INICC)
report, data summary of 30 countries, 2005–2010. Infect Control
Hosp Epidemiol. 2013;34:597–604.
7. Lunt N, Carrera P. Medical tourism: assessing the evidence on
treatment abroad. Maturitas. 2010;66(1):27–32.
8. Turner L. News media reports of patient deaths following ‘medical
tourism’ for cosmetic surgery and bariatric surgery. Dev World
Bioeth. 2012;12(1):21–34.
9. Chen LH, Wilson ME. The globalization of healthcare: implica-
tions of medical tourism for the infectious disease clinician. Clin
Infect Dis. 2013;57(12):1752–9.
44 Postoperative Complications Following Surgery Abroad
499
10. Allegranzi B, Bagheri Nejad S, Combescure C, et al. Burden of
endemic health-care-associated infection in developing countries:
systematic review and meta-analysis. Lancet. 2011;377:228–41.
11. Stramer SL, Linnen JM, Carrick JM, et al. Dengue viremia in blood
donors identifi ed by RNA and detection of dengue transfusion
trans- mission during the 2007 dengue outbreak in Puerto Rico.
Transfusion. 2012;52:1657–66.
12. Hodges JR, Kimball AM. Unseen travelers: medical tourism and
the spread of infectious disease. Risks and challenges in medical
tourism: understanding the global market for health services. Santa
Barbara: Praeger; 2012. p. 111–37.
13. Kennedy K, Collignon P. Colonization with Escherichia coli resistant to “critically important” antibiotics: a high risk for international travellers. Eur J Clin Microbiol Infect Dis. 2010;29:
1501–6.
14. World Health Organization. WHO proposes global agenda on transplantation. 2007.
2007/pr12/en/index/html
15. Yea S. Traffi cking in part (s): the commercial kidney market in a
Manila slum, Philippines. Glob Soc Policy. 2010;10(3):358–76.
16. Sajjad I, Baines LS, Patel P, Salifu UO, Jindal RM. Commercialization
of kidney transplants: a systematic review of outcomes in recipients
and donors. Am J Nephrol. 2008;28:744–54.
17. Anker AE, Feeley TH. Estimating the risks of acquiring a kidney
abroad: a meta-analysis of complications following participation in
transplant tourism. Clin Transpl. 2012;26:E232–41.
18. Canales MT, Kasiske BL, Rosenberg ME. Transplant tourism: outcomes of United States residents who undergo kidney transplantation overseas. Transplantation. 2006;82(12):1658–61.
19. Metlikovec J. Warning on cheap “holiday” surgeries. 2007.
www.news.com.au/travel/story/0,00.html
http://www.who.int/mediacentre/new/releases/
.
http://
26058.
20. Connell J. Medical tourism: sea, sun, sand and… surgery. Tour
Manag. 2006;27(6):1093–100.
21. Birch J, Caulfi eld R, Ramakrishnan V. The complications of ‘cosmetic tourism’–an avoidable burden on the NHS. J Plast Reconstr
Aesthet Surg. 2007;60(9):1075–7.
22. Jeevan R, Armstrong A. Cosmetic tourism and the burden on the
NHS. J Plast Reconstr Aesthet Surg. 2008;61(12):1423–4.
23. Melendez MM, Alizadeh K. Complications from international surgery tourism. Aesthet Surg J. 2011;31(6):694–7.
24. Partridge R, Bouslough D, Proano L. Disaster-related fatalities
among US citizens traveling abroad. Am J Disaster Med.
2012;8(2):123–6.
25. Missair A, Gebhard R, Pierre E, Cooper L, Lubarsky D, Frohock J,
Pretto EA. Surgery under extreme conditions in the aftermath of the
2010 Haiti earthquake: the importance of regional anesthesia.
Prehospital Disaster Med. 2010;25(06):487–93.
26. O’Connell C, Shivji A, Calvot T. Handicap international report:
earthquake of 12th January, 2010–Haiti: preliminary fi ndings about
persons with injuries. 29 Jan 2010. Available at
tiongivingback.facs.org/stuff/contentmgr/files/f3c4e87c7ceca489d3197cab5d6de592/miscdocs/pinternational_preliminary
fi ndingsaboutinjuries_1feb2010.pdf
27. Landry MD, O’Connell C, Tardif G, Burns A. Post-earthquake
Haiti: the critical role for rehabilitation services following a humanitarian crisis. Disabil Rehabil. 2010;32(19):1616–8.
28. Stewart B, et al. Global disease burden of conditions requiring
emergency surgery. Br J Surg. 2014;101(1):e9–22.
29. Sharma D, et al. Surgery for conditions of infectious etiology in
resource-limited countries affected by crisis: the Médecins Sans
Frontières Operations Centre Brussels experience. Surg Infect.
2015;16:721–7.
.
http://www.opera-
Post-intensive Care Syndrome (PICS)
Jed Wolpaw , Stephanie Cha , and Todd Dorman
4 5
Introduction
More than fi ve million patients are admitted to intensive care
units (ICUs) in the United States annually, and almost 90 %
are surviving to discharge [
quences of critical illness are growing in importance and
gaining more attention as demand for critical care grows and
the short-term mortality after critical illness decreases. The
number of survivors living with chronic critical illness has
increased, and, unable to care for themselves, these patients
are often discharged to long-term care facilities. Between
2001 and 2012, the percentage of ICU survivors discharged
to these facilities rose from 15 to 25 % [ 3 – 6 ].
Both physical and psychiatric sequelae of critical illness
can persist for years after discharge (see Table 45.1 ) [ 2 ]. Up
to 85–95 % of ICU survivors struggle with persistent weakness, 50–70 % have diffi culties completing activities of daily
living, 30–80 % have cognitive impairment, and more than
50 % manifest various forms of psychiatric morbidity [ 2 ].
The presence of impairment in survivors’ mental health, cognitive function, or physical function has been termed postintensive care syndrome (PICS) (see Fig. 45.1 ) [ 3 ].
Psychiatric morbidity affects not only the surviving patient
but their caregivers as well. This phenomenon has been
termed post-intensive care syndrome-family (PICS-F) (see
Fig. 45.1 ) [ 3 , 7 ]. The impairments of PICS and PICS-F lead
to an inability for survivors and family members to return to
the workforce and increased healthcare utilization [ 2 , 8 ].
It is becoming clear that discharge from the ICU no longer represents the end of critical illness. The ongoing physical, cognitive, and psychiatric suffering of survivors and the
psychiatric suffering of their caregivers can last for years [ 2 ,
9 ]. The number of studies on this topic has greatly increased
J. Wolpaw , MD, MEd (*) • S. Cha , MD • T. Dorman , MD
Anesthesiology and Critical Care Medicine , Johns Hopkins
Hospital , Baltimore , MD , USA
jwolpaw1@jhmi.edu; scha4@jhmi.edu;
e-mail:
tdorman@jhmi.edu
1 , 2 ]. The long-term conse-
between 2010 and 2015 compared with the 5 years prior
[
10 ]. Familiarity with the physical, cognitive, and psychiatric
challenges (see Table
not only during but after their ICU stay and the interventions
that can mitigate the sequelae of critical illness will help clinicians better serve their patients and their patients’
families.
45.1 ) faced by patients and families
Physical Impairment
A 2005 review of over 7,000 ICU survivors found that most
survivors experienced a signifi cant reduction in quality of
life (QOL) in the months following ICU discharge, including
impairment in role functioning due to physical problems
[ 11 ]. Post-ICU long-term physical impairment is therefore
an increasing public health concern and encompasses general physical dysfunction, pulmonary dysfunction, and neuromuscular dysfunction.
Physical Dysfunction
Physical dysfunction is commonly reported in ICU survivors. Outcome measures such as performance of activities
of daily living and 6-min walk distance (6MWD) are almost
universally impaired at hospital discharge and frequently
persist at the 1-year mark [
in almost one-third of survivors at 1-year follow-up [ 14 ,
15 ]. Studies of ARDS survivors have identifi ed several
potential risk factors, including exposure to systemic corticosteroids, development of illness acquired within the ICU
stay, and slow resolution of lung injury and multi-organ
dysfunction [ 16 ]. Treatment strategies generally favor the
implementation of early structured and individualized rehabilitation in concordance with sedation lightening [
In fact, patients exposed to early mobilization are able to
ambulate further at hospital discharge. One study of
mechanically ventilated patients found that those subjected
12 – 14 ]. Severe disability occurs
17 – 19 ].
© Springer International Publishing Switzerland 2016
N.D. Martin, L.J. Kaplan (eds.), Principles of Adult Surgical Critical Care, DOI 10.1007/978-3-319-33341-0_45
501
502
Table 45.1 Selected potential long-term patient and family outcomes after intensive care
Complication Description Selected risk factors Natural history
Patient outcomes
Pulmonary Impairment in spirometry, lung
volumes, and diffusion
capacity
Neuromuscular/ICU-acquired
weakness
Physical function Disuse atrophy Immobility/bed rest Some improvement in ADL
Psychiatric Depression Traumatic/delusional memories of
Cognitive Impairments in memory,
Family outcomes
Psychiatric Depression Overall risk factors: female gender,
From Needham et al. [
ADL activities of daily living, IADL instrumental activities of daily living, ICU intensive care unit
3 ]
Includes critical illness
polyneuropathy and myopathy
Impairment in activities of
daily living (ADL/IADL) and
6-min walk distance
Post-traumatic stress disorder Sedation, agitation, physical
Anxiety Unemployment, duration of
attention, executive function,
mental processing speed,
visuospatial ability
Post-traumatic stress disorder Dissatisfaction with communication,
Anxiety Severity of illness not associated with
Complicated grief Complicated grief is worse when
Diffusion capacity: duration of
mechanical ventilation
Hyperglycemia Polyneuropathy may recover
Systemic corticosteroids
ICU-acquired illnesses
Slow resolution of lung injury
Age
Preexisting IADL impairment
ICU, sedation, psychiatric symptoms
at discharge, impairment of physical
function
restraints, traumatic/delusional
memories
mechanical ventilation
Overall risk factors: female gender,
younger age, less education, and
pre-ICU psychiatric symptoms, and
personality
Lower pre-ICU intelligence Signifi cant improvement
ICU delirium
Sedation
Hypoxia
Glucose dysregulation
younger age, less education, pre-ICU
psychiatric symptoms, personality,
distance to hospital, restricted visiting
ICU physician perceived as
“uncaring,” passive preference for
decision-making, mismatch between
involvement in decision-making and
preference
development of symptoms
family does not have knowledge of
patient’s wishes
In pediatric ICU, paternal stress after
discharge is associated with child
stress in pediatric ICU
Generally mild impairment
with improvement during fi rst
year, but can persist 5 years or
more
more slowly than myopathy;
can extend to 5 years
within months, but
impairments may be seen in
ADL at 1 year and in IADL at
2 years
May decrease over fi rst year
Little improvement in fi rst year
May persist past fi rst year
during fi rst year, with residual
defi cits up to 6 years later
Depression and anxiety
decrease over time, but are
higher than population norms
at 6 months
Post-traumatic stress disorder
and complicated grief can
persist 4 years or more after
death or discharge and may not
decrease over time
J. Wolpaw et al.
to early mobilization ambulated a mean of 30.4 m, compared with a median of 0 m in control patients [
17 ].
Specifi cally, quality improvement measures which focus on
reducing the use of continuous administration of benzodiazepines, increasing ICU staffi ng for physical and occupational therapy, and updating consultative guidelines to
45 Post-intensive Care Syndrome (PICS)
503
Post Intensive
Care Syndrome
(PICS)
Family
(PICS-F)
Mental Health
Anxiety/ASD
PTSD
Depression
Complicated Grief
Fig. 45.1 Post-intensive care syndrome (PICS) conceptual diagram. ASD acute stress disorder, PTSD post-traumatic stress disorder (From
Needham et al. [
3 ] )
Mental Health
Anxiety/ASD
PTSD
Depression
facilitate early rehabilitation have been shown to improve
the functional mobility of ICU patients and reduce both
ICU and hospital length of stay [ 59 ].
Survivor
(PICS)
Cognitive Impairments
Executive Function
Memory
Attention
Visuo-spatial
Mental Processing Speed
Physical
Impairments
Pulmonary
Neuromuscular
Physical Function
a syndrome with the hallmarks of generalized weakness and
inability to separate from mechanical ventilation [ 25 ].
Weakness is increasingly prevalent, occurring in up to 50 %
of patients with sepsis, multi-organ failure, or protracted
mechanical ventilation [ 25 ]. Consequences are signifi cant
Pulmonary Dysfunction
both in the acute-care setting, as well as in the long-term
recovery period, affecting mortality, ICU length of stay, hos-
Most data regarding pulmonary dysfunction comes from that
of long-term ARDS survivors. When present, dysfunction is
usually mild and may present as impairment in diffusion
capacity, obstructive lung disease, or restrictive lung disease
[ 20 , 21 ]. Impairment in diffusion capacity is the most common
type of pulmonary dysfunction and may persist in up to 80 %
ARDS survivors at the 1-year mark [ 16 , 21 ]. Obstructive and
pital length of stay, duration of mechanical ventilation, and
duration of post-ICU rehabilitation [ 25 – 27 ]. Patients with
critical illness-associated weakness often experience persistent physical defi cit and disability, impeding activities such
as independent walking and spontaneous ventilation [ 28 ].
Furthermore, physical disability has been noted to persist in
follow-up periods for as long as 5 years [ 29 ].
restrictive defects typically normalize by 1 year [ 16 ]. Multiple
indicators of poor pulmonary function, such as forced expiratory volume in 1 s (FEV1), ratio of FEV1 to vital capacity, and
diffusion capacity for carbon monoxide, have been shown to
correlate with a decline in overall health- related quality of life
[ 22 , 23 ]. Pulmonary dysfunction and diffusion capacity in par-
ticular may be associated with the duration and mode of
mechanical ventilation [ 22 , 24 ]. In addition, prolonged dia-
phragmatic inactivity seen with extended duration mechanical
ventilation is known to precipitate diaphragmatic atrophy and
subsequent dysfunction as the diaphragm thins and undergoes
a change in curvature [ 46 ].
ICU-Acquired Weakness
The term ICU-acquired weakness (IAW) was developed in an
effort to standardize nomenclature used for describing clinically apparent weakness in ICU patients [ 3 , 30 ]. It embodies
several distinct but overlapping entities, including critical illness polyneuropathy (CIP), critical illness myopathy (CIM),
and critical illness neuromyopathy (CINM), which occur
when features of both CIP and CIM are present. There are
several modalities of testing which can aid in the diagnosis of
IAW. These include clinical assessment, electrophysiologic
testing (needle EMG, nerve conduction studies, neuromuscular junction testing), and morphologic investigation (nerve histology and muscle biopsy). Diagnosis is often challenging due
Neuromuscular Dysfunction
to the high prevalence of altered mental status in ICU patients
and inability to elicit voluntary muscle contraction, as well as
Neuromuscular dysfunction has long been observed in conjunction with critical illness and can be thought to comprise
the common presence of tissue edema, which can impair accurate needle EMG or nerve conduction study. Clinical assess-
504
J. Wolpaw et al.
ment is done by manual muscle testing in concordance with
the previously validated Medical Research Council scoring
system in which three muscle groups of each extremity are
scored from 0 to 5 for a maximal strength score of 60 and a
score <48 qualifying for IAW [
30 , 31 ]. Recent research also
explores the use of biomarkers, such as CK level, and ultrasound measurement of muscle thickness to detect the presence
of and quantify the extent of IAW, but these methods have yet
to be fully delineated [ 32 – 35 ]. Ultimately, however, the diag-
nosis of IAW must be made by exclusion, and a careful history
and physical examination is an essential part of the initial
investigation (see Table 45.2 ).
Critical Illness Polyneuropathy
CIP is manifested by proximal extremity and respiratory
muscle weakness, with sparing of facial and ocular muscle
groups (see Table
45.3 ). Respiratory weakness may be sig-
nifi cant enough to prolong weaning from mechanical ventilation [
36 ]. Sensory defi cits are less common and usually
involve distal extremity loss of pain, temperature, and vibratory sensation. Deep tendon refl exes may be absent or
depressed. CIP occurs following secondary nerve axonal
injury in the absence of demyelination. When present, it carries a poorer prognosis for recovery compared with CIM
[ 37 ]. Nerve conduction studies demonstrate a reduction in
compound muscle action potentials (CMAPs) and sensory
nerve action potentials (SNAPs) with preservation of nerve
conduction velocities (NCVs) [ 30 ]. Repetitive nerve stimu-
lation of the neuromuscular junction does not produce a
decline in muscle response. The pathophysiology is likely
multifactorial, and proposed mechanisms include reduction
of sodium ion channel excitability, nerve ischemia, and
impairment of the nerve microcirculation, which may be
exacerbated by local hypoxia or hyperglycemia and downstream dysregulation of nerve mitochondria [ 38 – 42 ].
Supporting studies demonstrate increased expression of
E-selectin proteins in the peripheral nerve vascular endothelium, which may be responsible for microvascular leak and
the strong association between CIP and sepsis [
25 , 42 ].
Critical Illness Myopathy
CIM describes a primary myopathy, without involvement of
the sensory system [
28 ]. Clinically, it can be very diffi cult to
distinguish from CIP by simple bedside examination since both
entities may be manifested by respiratory and limb muscle
weakness (see Table 45.4 ). In CIM, nerve conduction studies
demonstrate reduction of CMAPs, with preserved NCVs and
SNAPs, direct muscle stimulation reveals reduced excitability,
and histology is consistent with myopathy [ 30 ]. Mechanisms
of pathophysiology include skeletal muscle wasting from an
overall catabolic state often present in critical illness and sepsis, systemic infl ammation and oxidative injury, mitochondrial
dysfunction, and sodium channelopathy [ 41 , 43 – 45 ]. Muscle
atrophy is likely precipitated by prolonged immobilization and
diaphragmatic inactivity, which in turn leads to protease activation, muscle protein breakdown, and proteolysis by the ubiquitin-proteasome pathway [ 46 – 48 ]. Support for disuse atrophy is
demonstrated by the loss of diaphragmatic thick fi laments and
increase in proteolysis observed after diaphragmatic inactivity
for as little as 16 h [ 48 ].
Risk Factors
Clear risk factors for the development of IAW include sepsis,
states of persisting systemic infl ammation, catabolic state, and
multi-organ failure. Prolonged immobilization, long duration
of mechanical ventilation, and long ICU length of stay, in addi-
Table 45.2 Diagnostic criteria for ICU-acquired weakness
1. Generalized weakness developing after the onset of critical illness
2. Weakness is diffuse (involving both proximal and distal muscles), symmetric, fl accid, and generally spares cranial nerves
3. MRS sumscore <48 or mean MRC score <4 in all testable muscle groups noted on ≥2 occasions separated by >24 h
4. Dependence on mechanical ventilation
5. Causes of weakness not related to the underlying critical illness have been excluded
Minimum criteria for diagnosing ICUAW: 1, 2, 3 or 4, 5
From Stevens et al. [
ICUAW intensive care unit-acquired weakness, MRC Medical Research Council
a
For example, facial grimace is intact
Table 45.3 Diagnostic criteria for CIP
1. Patient meets criteria for ICUAW
2. Compound muscle action potential amplitudes are decreased to <80 % of lower limit of normal in ≥2 nerves
3. Sensory nerve action potential amplitudes are decreased to <80 % of lower limit of normal in ≥2 nerves
4. Normal or near-normal nerve conduction velocities without conduction block
5. Absence of a decremental response on repetitive nerve stimulation
From Stevens et al. [
CIP critical illness polyneuropathy, ICUAW intensive care unit-acquired weakness
30 ]
30 ]
a