Chronic critical illness in polytrauma. Results of the Spanish trauma in ICU registry

Definitions, epidemiology, and outcomes of persistent/chronic critical illness: a scoping review for translation to clinical practice

BACKGROUND

Medical advances in intensive care units (ICUs) have resulted in the emergence of a new patient population-those who survive the initial acute phase of critical illness, but require prolonged ICU stays and develop chronic critical symptoms. This condition, often termed Persistent Critical Illness (PerCI) or Chronic Critical Illness (CCI), remains poorly understood and inconsistently reported across studies, resulting in a lack of clinical practice use. This scoping review aims to systematically review and synthesize the existing literature on PerCI/CCI, with a focus on definitions, epidemiology, and outcomes for its translation to clinical practice.

METHODS

A scoping review was conducted using MEDLINE and Scopus, adhering to the PRISMA-ScR guidelines. Peer-reviewed original research articles published until May 31, 2024 that described adult PerCI/CCI in their definitions of patient populations, covariates, and outcomes were included. Data on definitions, epidemiology, and outcomes were extracted by a data charting process from eligible studies and synthesized.

RESULTS

Ninety-nine studies met the inclusion criteria. Of these studies, 64 used the term CCI, 18 used PerCI, and 17 used other terms. CCI definitions showed greater variability, while PerCI definitions remained relatively consistent, with an ICU stay ≥ 14 days for CCI and ≥ 10 days for PerCI being the most common. A meta-analysis of the prevalence of PerCI/CCI among the denominators of "all ICU patients", "sepsis", "trauma", and "COVID-19" showed 11% (95% confidence interval 10-12%), 28% (22-34%), 24% (15-33%), and 35% (20-50%), respectively. A meta-analysis of in-hospital mortality was 27% (26-29%) and that of one-year mortality was 45% (32-58%). Meta-analyses of the prevalence of CCI and PerCI showed 17% (16-18%) and 18% (16-20%), respectively, and those for in-hospital mortality were 28% (26-30%) and 26% (24-29%), respectively. Functional outcomes were generally poor, with many survivors requiring long-term care.

CONCLUSIONS

This scoping review synthesized many studies on PerCI/CCI, highlighting the serious impact of PerCI/CCI on patients' long-term outcomes. The results obtained underscore the need for consistent terminology with high-quality research for PerCI/CCI. The results obtained provide important information to be used in discussions with patients and families regarding prognosis and care options.

The obesity paradox and 90 day mortality in chronic critically ill patients: a cohort study using a large clinical database

BACKGROUND

This study investigates the obesity paradox, where obesity is linked to lower mortality in certain patient groups, focusing on its impact on long-term mortality in chronic critically ill (CCI) patients.

METHODS

We retrospectively analyzed CCI patients from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database's Intensive Care Unit, categorizing them into six groups based on Body Mass Index (BMI). Using stepwise multivariable Cox regression and restricted cubic spline models, we examined the association between BMI and 90 day mortality, accounting for confounding variables through subgroup analyses.

RESULTS

The study included 1996 CCI patients, revealing a 90 day mortality of 34.12%. Overweight and obese patients exhibited significantly lower mortality compared to normal-weight individuals. Adjusted analysis showed lower mortality risks in overweight and obese groups (HRs 0.60 to 0.72, p < 0.001). The cubic spline model indicated a negative correlation between BMI and 90 day mortality, with subgroup analyses highlighting interactions with age.

CONCLUSION

Our findings confirm the obesity paradox in CCI patients, especially among the elderly (65-85 years) and very elderly (≥ 85 years). The results suggest a beneficial association of higher BMI in older CCI patients, though caution is advised for those under 45.

CHRONIC CRITICAL ILLNESS-INDUCED MUSCLE ATROPHY: INSIGHTS FROM A TRAUMA MOUSE MODEL AND POTENTIAL MECHANISM MEDIATED VIA SERUM AMYLOID A

ABSTRACT

Background: Chronic critical illness (CCI), which was characterized by persistent inflammation, immunosuppression, and catabolism syndrome (PICS), often leads to muscle atrophy. Serum amyloid A (SAA), a protein upregulated in critical illness myopathy, may play a crucial role in these processes. However, the effects of SAA on muscle atrophy in PICS require further investigation. This study aims to develop a mouse model of PICS combined with bone trauma to investigate the mechanisms underlying muscle weakness, with a focus on SAA. Methods: Mice were used to examine the effects of PICS after bone trauma on immune response, muscle atrophy, and bone healing. The mice were divided into two groups: a bone trauma group and a bone trauma with cecal ligation and puncture group. Tibia fracture surgery was performed on all mice, and PICS was induced through cecal ligation and puncture surgery in the PICS group. Various assessments were conducted, including weight change analysis, cytokine analysis, hematological analysis, grip strength analysis, histochemical staining, and immunofluorescence staining for SAA. In vitro experiments using C2C12 cells (myoblasts) were also conducted to investigate the role of SAA in muscle atrophy. The effects of inhibiting receptor for advanced glycation endproducts (RAGE) or JAK2 on SAA-induced muscle atrophy were examined. Bioinformatic analysis was conducted using a dataset from the GEO database to identify differentially expressed genes and construct a coexpression network. Results: Bioinformatic analysis confirmed that SAA was significantly upregulated in muscle tissue of patients with intensive care unit-induced muscle atrophy. The PICS animal models exhibited significant weight loss, spleen enlargement, elevated levels of proinflammatory cytokines, and altered hematological profiles. Evaluation of muscle atrophy in the animal models demonstrated decreased muscle mass, grip strength loss, decreased diameter of muscle fibers, and significantly increased expression of SAA. In vitro experiment demonstrated that SAA decreased myotube formation, reduced myotube diameter, and increased the expression of muscle atrophy-related genes. Furthermore, SAA expression was associated with activation of the FOXO signaling pathway, and inhibition of RAGE or JAK2/STAT3-FOXO signaling partially reversed SAA-induced muscle atrophy. Conclusions: This study successfully develops a mouse model that mimics PICS in CCI patients with bone trauma. Serum amyloid A plays a crucial role in muscle atrophy through the JAK2/STAT3-FOXO signaling pathway, and targeting RAGE or JAK2 may hold therapeutic potential in mitigating SAA-induced muscle atrophy.

PREVALÊNCIA E FATORES ASSOCIADOS À DOENÇA CRÍTICA CRÔNICA EM HOSPITALIZADOS POR TRAUMA EM TERAPIA INTENSIVA

RESUMO Objetivo identificar a prevalência de doença crítica crônica e fatores associados em pacientes hospitalizados por trauma em Unidade de Terapia Intensiva. Método estudo de caso-controle, com dados de prontuários de adultos hospitalizados por trauma em uma Unidade de Terapia Intensiva, entre 2013 e 2019. Os dados foram coletados do livro de admissão de pacientes, do prontuário eletrônico e das fichas do Serviço de Controle de Infecção Hospitalar. A variável dependente foi a ocorrência de doença crítica crônica e as variáveis independentes relacionavam-se às características sociodemográficas, comorbidades, trauma, atendimento pré-hospitalar, índices prognósticos, procedimentos e complicações. Realizou-se análise de regressão logística múltipla, que estimou o Ods Ratio (OR) e respectivos intervalos de confiança (IC). Resultados a doença crítica crônica ocorreu em 150 pacientes (24,2%), dos 619 estudados. Os fatores associados à DCC foram disfunção orgânica (OR=1,09) e complicações gastrointestinais (OR=2,71). Os pacientes com doença crítica crônica, além de demandarem por procedimentos cirúrgicos, desenvolveram disfunções orgânicas em diferentes sistemas, apresentando altas pontuações nos índices de prognósticos, ou seja, um pior prognóstico, além de desenvolverem complicações. Conclusão a identificação das complicações gastrointestinais e o aumento da disfunção orgânica como fatores associados ao paciente crítico crônico tornam-se úteis para compor perfil clínico de pacientes e para planejar a assistência intensiva ao traumatizado, contribuindo, assim, para a prevenção e o manejo desses pacientes pelo enfermeiro.

PREVALENCE AND FACTORS ASSOCIATED WITH CHRONIC CRITICAL DISEASE IN HOSPITALIZED FOR TRAUMA IN INTENSIVE CARE

ABSTRACT Objective to identify the prevalence of chronic critical disease and associated factors in patients hospitalized for trauma in the Intensive Care Unit. Method case-control study, with data from medical records of adults hospitalized for trauma in an Intensive Care Unit, between 2013 and 2019. Data were collected from the patient admission book, the electroni cmedical records and the records of the Hospital Infection Control Service. The dependent variable was the occurrence of chronic critical disease, and the independent variables were related to sociodemographic characteristics, comorbidities, trauma, pre-hospital care, prognostic indices, procedures and complications. Multiple logistic regression analysis was performed, which estimated the Ods Ratio (OR) and respective confidence intervals (CI). Results chronic critical disease occurred in 150 patients (24.2%), of the 619 patients studied. The factors associated with CCD were organic dysfunction (OR=1.09) and gastrointestinal complications (OR=2.71). Patients with chronic critical disease, in addition to proseeding for surgical procedures, developed organic dysfunctions in different systems, presenting high scores in prognostic indexes, i.e., a worse prognosis, in addition to developing complications. Conclusion the identification of gastrointestinal complications and the increase in organic dysfunction as factors associated with chronic critical patients become useful to compose the clinical profile of patients and to plan intensive care for the traumatized patients, thus contributing to the prevention and management of these patients by nurses.