ICM Viva - Rehab

Question 1

Importance of rehab

Answer 1

Regain quality of life after critical illness

Reduce economic burden

• ongoing medical/psych care
• patient earning
• Carers and family members
• government benefits

Question 2

Why do we need rehab

Answer 2

Physical problems
Weakness

Can’t self care/work

25% of pts need help with self care.

Psych - relationships, normal activity’s

Question 3

Outline the ongoing rehab issues

Answer 3

Physical, Psych, Nutiriton, Pain, Drugs

Physical
- weak, stiff, paraetheisa
- Postural hypotension
- Low CV reserve
- Incontinence, sexual dysfunction, communication issues (trachy)
- Iatrogenic - tracheal stenosis etc

Psych
- anxiety, PTSD, survivors guilt, depression, guilt for relatives/burden
- Effect of scars/marks
- Poor sleep cycle (related to opiates/benzos)
- Cognition - memory, low attention, confused, apathy

Nutrition
- low appetite
- altered taste and smell, swallowing

Chronic pain

Drug withdrawal

Ongoing organ support - RRT, nutrition, VADs

Question 4

How to test whether rehab has worked

Answer 4

Health Related QoL tools - SF36 (Short Form Health Survey), EuroQol 5d (mobility, self care, actives, pain, anxiety)

Beware loss to follow up (those who do well will want to tell you)

Use of follow up clinics - NICE guidance
Poor uptake, evidence for usefulness?? Too sick to go, too well to go.

PRACTICAL study - nurse led follow up - no benefit

Question 5

How can we improve a patients rehabilitation?

Answer 5

NICE CG83 and ICS rehab prescriptions

Intervene early!
Assess the patient and their rehab needs
Any pre-existing issues

Set goals - short (before discharge), medium (normal activity)

Consider CPAx (Chelsea critical care physical assessment tool).

Debrief family and patient.

MDT, things to reduce ICU-AW

Follow up, recovery times

Question 6

What is PTSD

Answer 6

9-27% of ITU survivors

Severe anxiety triggered by recurrent re-living of life events

Lasts over a month

Impairs social function

Triad - intrusive unpleasant flashbacks
Avoidance behaviours
Increased level of alertness

Question 7

Risk factors for PTSD? Prevention?

Answer 7

Previous psych issues
Sedation and prolonged MV
Benzos
Delirium
ARDS
Sepsis

Factual memory reduces PTSD - follow up clinic may allow to address flashback

Diaries - though evidence is mixed

Question 8

Role of outpatient clinic

Answer 8

Early diagnosis of sequela and refer
Long term outcome data
Patient feedback
Advise/reassures
Assess previous decision making

Question 9

What are some of the common side effects of Prolonged ICU stay

Answer 9

Social Isoloation
- Financial
- Change in relationship - unable to do