critical disease; critical illness; critically ill patient; critical condition
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Introduction
Also see critical illness syndrome, critical care medicine & intensive care unit
Etiology
Pathology
- pituitary-independent increase in cortisol production
- decrease in plasma cortisol clearance
- euthyroid sick syndrome (75%)[3]
Clinical manifestations
- vital signs are unstable
- altered state of consciousness common
Laboratory
- serum cortisol is generally elevated[2]
- urinary free cortisol may be low[2]
- cosyntropin stimulation test not helpful in critically ill patients[2]
- serum TSH only when suspicion of thyroid disorder is high[3]
Diagnostic procedures
- continuous EEG decreases mortality in critically ill hospitalized patients[14]
- lower mortality for subarachnoid hemorrhage or intracranial hemorrhage, altered consciousness, encephalopathy, & delirium
- mortality for seizure or status epilepticus not affected[14]
Complications
- high risk of mortality
- premorbid disability, poor functional status, & deteriorating functional trajectory in the elderly associated with highest 1 year mortality[9]
- critical illness neuropsychiatric impairment
- critical illness cognitive impairment (persisting > 5 years)[4][21]
- mood disorders (depression, anxiety, PTSD ..(persisting > 8 years)[21]
- critical illness weakness[21]
- frailty (functional disability, nursing home admission)[21]
- nutritional deficiency (physical & neurocognitive recovery compromised)[21]
- pressure ulcers (persisting > 1 year)[21]
- oral complications (gingivitis, dental caries, tooth loss)[21]
- endocrinopathies (thyroid disorders, adrenal disorders, pituitary disorders)[21]
- entrapment neuropathy (foor drop & wrist drop)[21]
- musculoskeletal disorders (frozen joints, contractures, heterotopic calcification)[21]
- non-convulsive status epilepticus (altered mental status without clear cause)
- emergency department (ED) crowding & boarding harms critically-ill patients[12]
- combined outcome of in-hospital mortality, persistent organ dysfunction (vasopressors, mechanical ventilation, dialysis) or death at 28 days increases from ~25% at hour 0 to 40% at hour 12 for critically-ill patients boarded in the ED
- 47% of ICU admission requests from the ED are declined[7]
Management
- medical or surgical care provided in:
- nutritional support
- preferentially initiate enteral nutrition vs parenteral nutrition[9]
- parenteral & enteral feeding with similar outcomes[6][11]
- bowel ischemia more common with enteral nutrition vs parenteral nutrition (19 vs 5), but mortality, infections, length of hospital stay & extubation similar[11]
- 25-30 kcal/kg/day[9]
- standard isotonic formula tube feeds for most ICU patients[9]
- no special formulation is needed for patients with respiratory failure or liver failure
- special formulations for patients with renal failure should be considered when electrolyte disorders are present
- nasojejuenal tube for patients at high risk for aspiration
- prokinetic agents may be of benefit
- gastric residual volumes should not be used to guide feeding[9]
- vitamin D3 without benefit for vitamin D-deficient critically ill patients[15]
- preferentially initiate enteral nutrition vs parenteral nutrition[9]
- oxygen therapy
- fluid resuscitation with normal saline vs lactated Ringer's result in similar outcomes[19]
- early mobilization of no benefit assessed at 6 months[20]
- adverse events, including severe oxygen desaturation, are more common
- patients with diabetes mellitus (type 1 or type 2) require intravenous insulin with dosing based on a validated algorithm with point-of-care monitoring every 1-2 hours[3]
- plasma glucose target for critically ill patients with hyperglycemia is 140-180 mg/dL[3]
- most patients approaching end-of-life prioritize symptom control & dying at home over survival time[17]
- palliative care meetings for families of patients with long ICU stays of no benefit[10]
More general terms
More specific terms
Additional terms
References
- ↑ 1.0 1.1 The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Initial trophic vs full enteral feeding in patients with acute lung injury: The EDEN randomized trial. JAMA 2012 Feb 22/29; 307:795 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22307571
Griffiths RD. Nutrition for critically ill patients: How much is enough? JAMA 2012 Feb 22/29; 307:845 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22307570 - ↑ 2.0 2.1 2.2 2.3 Boonen E et al. Reduced cortisol metabolism during critical illness. N Engl J Med 2013 Mar 19 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23506003 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1214969
- ↑ 3.0 3.1 3.2 3.3 3.4 Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 19. American College of Physicians, Philadelphia 2012, 2015, 2022.
- ↑ 4.0 4.1 Pandharipande PP et al. Long-term cognitive impairment after critical illness. N Engl J Med 2013 Oct 3; 369:1306 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24088092
- ↑ Adler SM1, Verbalis JG. Disorders of body water homeostasis in critical illness. Endocrinol Metab Clin North Am. 2006 Dec;35(4):873-94 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17127152
- ↑ 6.0 6.1 Harvey SE et al. Trial of the route of early nutritional support in critically ill adults. N Engl J Med 2014 Oct 1 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25271389
- ↑ 7.0 7.1 7.2 Arabi YM et al. Permissive underfeeding or standard enteral feeding in critically ill adults. N Engl J Med 2015 Jun 18; 372:2398 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25992505
- ↑ Ferrante LE, Pisani MA, Murphy TE, et al. Functional trajectories among older persons before and after critical illness. JAMA Intern Med. 2015;175(4):523-529. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25665067
Covinsky KE. The critical importance of functional status in critical illness. JAMA Intern Med. 2015;175(4):530. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25665038 - ↑ 9.0 9.1 9.2 9.3 9.4 9.5 Taylor BE, McClave SA, Martindale RG et al Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Crit Care Med. 2016 Feb;44(2):390-438. PMID: https://www.ncbi.nlm.nih.gov/pubmed/2677178
- ↑ 10.0 10.1 Carson SS, Cox CE, Wallenstein S et al Effect of Palliative Care-Led Meetings for Families of Patients With Chronic Critical Illness: A Randomized Clinical Trial. JAMA. 2016 Jul 5;316(1):51-62. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27380343
White DB. Strategies to Support Surrogate Decision Makers of Patients With Chronic Critical Illness: The Search Continues. JAMA. 2016 Jul 5;316(1):35-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27380340 - ↑ 11.0 11.1 11.2 Reignier J, Boisrame-Helms J, Brisard L et al. Enteral versus parenteral early nutrition in ventilated adults with shock: A randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2). Lancet 2017 Nov 8; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29128300
Van Dyck L, Casaer MP. Nutrition in the ICU: Sometimes route does matter. Lancet 2017 Nov 8 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29128299 - ↑ 12.0 12.1 Mathews KS, Durst, MS. Vargas-Torres C et al. Effect of emergency department and ICU occupancy on admission decisions and outcomes for critically ill patients. Crit Care Med 2018 Jan 30; PMID: https://www.ncbi.nlm.nih.gov/pubmed/29384780 https://journals.lww.com/ccmjournal/Abstract/publishahead/Effect_of_Emergency_Department_and_ICU_Occupancy.96357.aspx
- ↑ Higgs A, McGrath BA, Goddard C, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018 Feb;120(2):323-352. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29406182 <Internet> http://bjanaesthesia.org/article/S0007-0912(17)54060-X/fulltext
- ↑ 14.0 14.1 14.2 Hill CE, Blank LJ, Thibault D et al. Continuous EEG is associated with favorable hospitalization outcomes for critically ill patients. Neurology 2019 Jan 1; 92:e9. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/30504428 <Internet> http://n.neurology.org/content/92/1/e9
- ↑ 15.0 15.1 The National Heart, Lung, and Blood Institute PETAL Clinical Trials Network. Early high-dose vitamin D3 for critically ill, vitamin D-deficient patients. N Engl J Med 2019 Dec 26; 381:2529 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31826336 https://www.nejm.org/doi/10.1056/NEJMoa1911124
- ↑ 16.0 16.1 Deane AM, Little L, Bellomo R et al. Outcomes six months after delivering 100% or 70% of enteral calorie requirements during critical illness (TARGET): A randomized controlled trial. Am J Respir Crit Care Med 2020 Apr 1; 201:814. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31904995 https://www.atsjournals.org/doi/10.1164/rccm.201909-1810OC
- ↑ 17.0 17.1 Rubin EB, Buehler A, Halpern SD. Seriously ill patients' willingness to trade survival time to avoid high treatment intensity at the end of life. JAMA Intern Med 2020 Apr 6; PMID: https://www.ncbi.nlm.nih.gov/pubmed/32250436 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2763718
- ↑ 18.0 18.1 Gelissen H, de Grooth HJ, Smulders Y et al. Effect of low-normal vs high-normal oxygenation targets on organ dysfunction in critically ill patients: A randomized clinical trial. JAMA 2021 Aug 31; [e-pub] PMID: https://www.ncbi.nlm.nih.gov/pubmed/34463696 https://jamanetwork.com/journals/jama/article-abstract/2783810
- ↑ 19.0 19.1 Finfer S, Micallef S, Hammond N et al Balanced multielectrolyte solution versus saline in critically ill adults. N Engl J Med 2022 Jan 18; [e-pub] PMID: https://www.ncbi.nlm.nih.gov/pubmed/35041780 https://www.nejm.org/doi/10.1056/NEJMoa2114464
- ↑ 20.0 20.1 Paton M et al. The effect of mobilization at 6 months after critical illness - Meta-analysis. NEJM Evid 2023 Feb; 2:EVIDoa2200234. PMID: https://www.ncbi.nlm.nih.gov/pubmed/38320036 https://evidence.nejm.org/doi/10.1056/EVIDoa2200234
The TEAM Study Investigators and the ANZICS Clinical Trials Group. Early active mobilization during mechanical ventilation in the ICU. N Engl J Med 2022 Nov 10; 387:1747. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36286256 https://www.nejm.org/doi/10.1056/NEJMoa2209083 - ↑ 21.00 21.01 21.02 21.03 21.04 21.05 21.06 21.07 21.08 21.09 21.10 Herridge MS, Azoulay E. Outcomes after Critical Illness. N Engl J Med 2023; 388:913-924 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36884324 https://www.nejm.org/doi/full/10.1056/NEJMra2104669