A Novel Contemporary Disease: Protracted Weakness After ICU Discharge

What are the long-term effects of a prolonged stay in the ICU?

You come by to see your patient after she has been discharged from the ICU. She is staring at a tray of food in front of her, which is undisturbed. She has lost 15 lb during the past week of hospitalization in the ICU. You ask her why she isn’t eating and whether she is hungry. She says that she is famished but is so weak she can’t even feed herself.¹

Or, you are in your office, and you are evaluating a former star lacrosse player. Unfortunately, he required assisted ventilation while he was in the ICU for 6 days as a result of pneumonia. He apparently did well with antibiotic treatment and was discharged shortly thereafter. Now, more than 1 year later, he still has belowaverage strength and stamina for his age.1 He no longer is involved in athletic endeavors.

What do these 2 patients have in common, and why should primary care physicians be conversant with the problem? Both have sustained neuromuscular dysfunction as a result of critical illnesses requiring ICU stays. Because their disability is chronic, it will have to be repeatedly addressed by their primary physicians. The pathology also increases morbidity and mortality and may never allow these patients to return to baseline function. One study found that a decrease in handgrip strength in ICU patients after only 5 days of assisted ventilation independently increases mortality 4.5 times.²

POSSIBLE CAUSES OF ICU-RELATED WEAKNESS
The reasons why ICU stays can eventuate in such dramatic and long-lived weakness are not completely understood, especially when the disease leading to ICU admission is controlled. However, it is suspected that overuse of sedatives, immobilization, ventilator dependence (usually more than 7 days), and prolonged ICU and hospital stays all play a role.3 Patients with weakness typically have lost a significant amount of weight, some of which they do not gain back over time. Whether the specific disease that led to ICU admission also contributes is unknown.

PREVENTIVE STEPS IN THE ICU
The increasing prevalence of this disorder, as well as its profound implications and cost, is precipitating a “paradigm shift” in ICU management.3 Sedative use and cumulative doses have deliberately declined, and patients are undergoing early and regular mobility therapy while they are in the ICU-tubing, machines, and all. Starting therapy after patients are transferred to a hospital room or after discharge is too late: regular rehabilitation should begin in the ICU.

Data that show these maneuvers are effective have still not been collected. However, the maneuvers themselves are plausible as therapeutics and do not seem likely to have negative effects.

IMPLICATIONS FOR PRIMARY CARE
Even though most primary care physicians do not manage ICU patients without consultative input, understanding this complication of ICU admission with ventilator dependence is important. After your patient is discharged from the ICU, be patient and do not be surprised by slow progress and incomplete recovery. If you contribute to ICU management or oversight of quality committees, advocate for early mobilization and judicious use of sedatives. Future prospective studies of the paradigm shift in ICU management may be around the corner.

References:

REFERENCES:1. Kolata G. A tactic to cut I.C.U. trauma: Get patients up. Accessed August 14, 2009.
2. Ali NA, O’Brien JM Jr, Hoffmann SP, et al. Acquired weakness, handgrip strength, and mortality in critically ill patients. Am J Respir Crit Care Med. 2008; 178:261-268.
3. Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA. 2008;300:1685-1690.