ImpactofRehabilitationEarlyinICU.pptVIP

Impact of Rehabilitation Early in ICU Margaret Herridge MD MPH Associate Professor of Medicine Interdepartmental Division of Critical Care University of Toronto The Canadian Critical Care Trials Group Overview The Continuum of ICU Weakness Muscle and Nerve Injury after Critical Illness Early Mobility The Disease Weakness Mental Health Cognition Heterotopic Ossification   frozen joints contractures Taste changes Tracheal stenosis Renal Impairment Hearing Loss Alopecia Cosmesis- Scars from CVC, Art line, CT, drain sites striae Griffiths and Jones BMJ 1999:319(7207):427-9 Bronchiectasis Pulmonary fibrosis Ischemic digits Nerve and Muscle Brain Evidence of diaphragmatic atrophy and increased proteolysis at 18 hours of mechanical ventilation De Jonghe, B. et al. JAMA 2002;288:2859-2867 Ali N et al. AJRCCM 2008; 178:261-268 Herridge et al. N Engl J Med 2003; 348:683-93. Five-Year Outcomes in ARDS Herridge et al. NEJM 2011; 364: 1293-304 Persistent exercise limitation and reduction in Physical QOL at 5-years after ICU discharge Post-discharge Costs $28,350 Other Subsequent hospitalization Inpatient rehabilitation outpatient rehabilitation homecare pharmacy imaging and labs physicians Cheung et al AJRCCM 2006; 174: 538-544 Herridge et al. NEJM 2011; 364: 1293-304 CIPN CIPNM ICUAP CRIMYNE CINMA Incidence 25% - 60% surveillance, definition, diagnostic testing, bias, confounding, case-mix De Letter et al. Crit Care Med 2001; 29: 2281-6 DeJonghe et al. JAMA 2002; 288: 2859-67. Stevens et al. Int Care Med 2007; 33:1876-91 Hough et al. Int Care Med 2008 ICU-Acquired Weakness Critical Illness Polyneuropathy (CIP) Acute axonal sensory-motor polyneuropathy Injury related to microcirculatory damage Mediated by E-selectin and induced by proinflammatory cytokines Pure functional impairment in the absence of structural change Bolton et al. J Neurol Neurosurg Psychiatry 1986; 49: 563-573