Functional status and survival after ICU discharge

Historically, the college examiners have been interested mainly in the influence of age on the outcome of ICU stay. For instance, a detailed all-systems look at age-related changes in the response to critical illness can be found in Question 8 from the second paper of 2007:"What are the age related factors which adversely affect outcome in the elderly (>65 years) critically ill patient?" . Other similar questions include Question 9 from the first paper of 2012 (outcome from traumatic brain injury in the elderly), Question 30 from the first paper of 2009 (tools of functional assessment) and the identical  Question 17 from the first paper of 2006. The best most recent example of these was probably Question 25 from the second paper of 2023, which asked about "post intensive care syndrome".

Post Intensive Care Syndrome (PICS)

Though most people would intuitively agree that patients emerging from prolonged critical illness are extensively affected by their ordeal, most would not realise that There Is An Acronym For That. PICS is not new, but the concept of defining it as a syndrome is a relatively recent undertaking by the Society of Critical Care Medicine, who arrived at this after two days of probing the opinions and attitudes of thirty one representatives from "key professional organizations and groups, predominantly from North America, which are involved in the care of intensive care survivors". The result was a definition, which follows: 

Definition of Post Intensive Care Syndrome

by the SCCM,

"new or worsening impairments in physical, cognitive, or mental health status arising after
critical illness and persisting beyond acute care hospitalization"

Rawal et al (2017) define it as:

"new or worsening impairment in physical (ICU-acquired neuromuscular weakness), cognitive (thinking and judgment), or mental health status arising after critical illness and persisting beyond discharge from the acute care setting"

From Inoue et al (2019):

"physical, cognition, and mental impairments that occur during ICU stay, after ICU discharge or hospital discharge, as well as the long-term prognosis of ICU patients"

So fairly robust in retelling, the definition must consist of three domains, incorporating some element of physical function, cognitive function, and mental health (eg. PTDS). 
The rest of this topic area is organised around the headings suggested by Question 25 from the second paper of 2023, and by the very similar subheadings of the excellent paper by Rawal et al (2017) which almost directly address the points asked by the college:

Clinical manifestations of Post Intensive Care Syndrome

• Physical:
  • Weakness, disuse atrophy
  • Fatigue, reduced exercise tolerance
  • Impairment in activities of daily living
  • Impaired respiratory function, reduced lung volumes and diffusion capacity
• Cognitive:
  • Impairments in memory, attention, executive function, mental processing speed, visuo-spatial ability
• Mental:
  • Depression, PTSD, anxiety, sleep disturbance, sexual dysfunction

Risk factors for Post Intensive Care Syndrome

• Risk factors for post-ICU physical impairment:
  • Prolonged mechanical ventilation (> 7 days)
  • Sepsis
  • Multisystem organ failure
  • Hyperglycaemia
  • Systemic corticosteroids
  • Age
  • Pre-existing functional impairment
• Risk factors for post-ICU cognitive impairment:
  • Sedation
  • Hypoxia
  • ICU delirium
  • Pre-exisitng cognitive impairment
• Risk factors for post-ICU mental illness:
  • Sedation
  • Delirium and agitation
  • Use of physical restraints

Prevention of Post Intensive Care Syndrome

• Elimination or correction of causative factors
  • Early extubation
  • Early mobilisation
• Monitoring for delirium and use of nonpharmacological strategies for its management
  • Using light or minimal sedation
  • Avoidance of physical restraints
• Reduction or elimination of sources of environmental stress, including
  • Minimising alarms
  • Minimising interruptions to sleep
• Frequent patient and family communication.

Consequences of prolonged intensive care stay

Question 30 from the first paper of 2009 asked about the "important problems encountered by the patient  following hospital discharge after a prolonged period of stay in the Intensive Care Unit." This question is heavily based on Oh's Manual Chapter 8 (Common  problems  after  ICU). If one were answering this question in the 2020s, one might be using the PICS definition above. Otherwise, a systematic list of problems would resemble the following:

• Tracheostomy:
  • Tracheal stenosis
  • Tethering of skin
• Mobility:
  • Muscle wasting, neuromyopathy
  • Slow recovery of normal function (up to 1 year)
• Skin
  • Hair loss
  • Nail ridging
  • MRSA colonisation
  • Facial scraring due to pressure areas from NGT and ETT
• Sexual dysfunction
  • a 39% incidence
• Psychological problems
  • PTSD, in about 15% (27.5% for ARDS survivors)

Tools to assess the functional outcome of intensive care survivors

Question 30 from the first paper of 2009  also asked the candidates to list two such tools. This was also derived from the abovementioned chapter of Oh's Manual , specifically Box 8.1 on page 62 of the new edition ("Quality of life tool examples").

The contents of this box:

• QALY(Quality Adjusted Life Years - the only objective tool)
• HAD (Hospital Anxiety and Depression)
• PQOL (Percieved Quality of Life)
• EuroQol
• SF 36 (36 item short-form survey)

Predictors of poor outcome in elderly survivors of traumatic brain injury

Determinants of poor prognosis in the head-injured elderly can be summarised thus:

• Age over 60
• GCS 3-5 on presentation
• Low GCS motor score
• Traumatic subarachnoid (worse outcome, as compared to other pathologies)
• Pupillary abnormalities

 Everyone seems to agree that age is a predictor of poor outcome. Steyerberg et al found that age was associated with poor neurological outcomes and decreased survival. Amacher et al also found that it doesn't matter how good your GCS is on admission, your old age will still play a role. In general, it seems being over 60 is a poor prognostic indicator. Think of that when you climb on the roof next time, grandpa.

I am struggling to figure out why the college in their answer to Question 9 from the first paper of 2012 thought a subdural is an indicator of poor prognosis.Steyerberg et al found that a traumatic subarachnoid (rather than subdural) was a determinant of poor prognosis. However, it is known that mortality in elderly patients with subdural haematoma is very high if they present with a GCS 3-5, losing points on motor scores. In fact, some authors felt that for these people craniotomy is not justified, because of the extremely poor outcomes overall, and a tendency to deteriorate in spite of satisfactory post-op CT scans.

Mortality in ICU

What is normal? How many of your patients should you be losing? A medical ICU surviving at the edges of a poor community with a busy emergency department will obviously differ from a surgical ICU of a private hospital that deals exclusively with carefully selected elective patients. Additionally it should be intuitive that the diagnosis with which you present to hospital should have some bearing on your mortality, as should the severity of your illness. But how much does each illness impact? Borrowing the multipliers from the "arrAP3" variable array in the back end of this ANZICS mortality risk calculator, it is possible to create a list of mortality multipliers which are used to calculate the APACHE III risk of death (for some reason they are not available in any easier form). These are not absolute risks per se, these are merely the multipliers applied to the rest of the score that are then used to arrive at the final risk of death, and represent numerically the contribution of each diagnosis to the final mortality prediction.

Yes, you can sort the table by clicking on the column header, we're not animals. 

Source	Category	APACHE III diagnosis	APACHE III code	APACHE III mortality coefficient
Non-operative	Cardiovascular	Cardiogenic Shock	101	0.78463
Non-operative	Cardiovascular	Cardiac Arrest	102	0.552243
Non-operative	Cardiovascular	Aortic Aneurysm	103	1.26578
Non-operative	Cardiovascular	Congestive Heart Failure	104	0
Non-operative	Cardiovascular	Peripheral Vascular Disease	105	0.13398
Non-operative	Cardiovascular	Rhythm Disturbance	106	-0.236138
Non-operative	Cardiovascular	Acute Myocardial Infarction	107	0.67761
Non-operative	Cardiovascular	Hypertension	108	-0.130588
Non-operative	Cardiovascular	Other Cardiovascular Disease	109	-0.291881
Non-operative	Cardiovascular	Cardiomyopathy	110	1.361203
Non-operative	Cardiovascular	Unstable Angina	111	-0.259457
Non-operative	Gastrointestinal	Hepatic Failure	301	0.296943
Non-operative	Gastrointestinal	GI Perforation/obstruction	302	0.252631
Non-operative	Gastrointestinal	GI Bleeding -varices	303	0.153806
Non-operative	Gastrointestinal	GI Inflammatory Disease (Colitis, pancreatitis)	304	-0.017995
Non-operative	Gastrointestinal	GI Bleeding -ulcer/laceration	305	0.021764
Non-operative	Gastrointestinal	GI Bleeding -diverticulosis	306	0.098954
Non-operative	Gastrointestinal	Other GI Disease	307	0.195821
Non-operative	Gastrointestinal	GI Perforation	308	-0.218601
Non-operative	Gastrointestinal	GI Obstruction	309	0.252631
Non-operative	Gastrointestinal	GI Vascular Insufficiency	310	0.198405
Non-operative	Gastrointestinal	Pancreatitis	311	0.088466
Non-operative	Gastrointestinal	GI cancer	312	1.391097
Non-operative	Gastrointestinal	Other GI Inflammatory disease	313	-0.017995
Non-operative	Haematological	Coagulopathy/Neutropaenia/Thrombocytopaenia	801	1.095134
Non-operative	Haematological	Other haematologic disorder	802	0.407784
Non-operative	Metabolic	Metabolic coma	701	-0.396898
Non-operative	Metabolic	Diabetic ketoacidosis	702	-1.919836
Non-operative	Metabolic	Drug overdose	703	-1.528488
Non-operative	Metabolic	Other metabolic disorder	704	-0.248306
Non-operative	Musculoskeletal/Skin	Musculoskeletal/Skin disease	1101	-0.130586
Non-operative	Musculoskeletal/Skin	Cellulitis/soft tissue infection	1102	0.13398
Non-operative	Neurological	Intracerebral Haemorrhage	401	1.520735
Non-operative	Neurological	Subarachnoid Haemorrhage	402	1.574573
Non-operative	Neurological	Stroke	403	0.879518
Non-operative	Neurological	Neurologic Infection	404	0.692197
Non-operative	Neurological	Neurologic Neoplasm	405	0.170705
Non-operative	Neurological	Neuromuscular Disease	406	-0.228204
Non-operative	Neurological	Seizure	407	-0.513583
Non-operative	Neurological	Other Neurologic Disease	408	0.133291
Non-operative	Neurological	Epidural haematoma	409	0.639308
Non-operative	Neurological	Coma	410	-0.396898
Non-operative	Other	Other medical disorders	1001	-0.130586
Non-operative	Other	Other medical disorders: nos	1002	0
Non-operative	Renal/Genitourinary	Renal disorders	901	-0.226863
Non-operative	Renal/Genitourinary	Pre-eclampsia	902	-0.130588
Non-operative	Renal/Genitourinary	Haemorrhage, postpartum (female only)	903	-0.291881
Non-operative	Respiratory	Aspiration Pneumonia	201	0.123363
Non-operative	Respiratory	Resp Neoplasm inc larynx/trachea	202	1.114274
Non-operative	Respiratory	Respiratory Arrest	203	0.300772
Non-operative	Respiratory	Pulmonary Oedema non cardiac.	204	0.741514
Non-operative	Respiratory	Bacterial/viral Pneumonia	205	0.356565
Non-operative	Respiratory	COPD	206	0.437855
Non-operative	Respiratory	Pulmonary Embolism	207	0.214629
Non-operative	Respiratory	Mechanical Airway Obstruction	208	0.916672
Non-operative	Respiratory	Asthma	209	-0.738478
Non-operative	Respiratory	Parasitic Pneumonia	210	1.240371
Non-operative	Respiratory	Other Respiratory Diseases	211	0.219583
Non-operative	Respiratory	Bacterial Pneumonia	212	0.356565
Non-operative	Respiratory	Viral Pneumonia	213	0.524507
Non-operative	Sepsis	Sepsis other than urinary	501	0.353941
Non-operative	Sepsis	Sepsis of Urinary Tract Origin	502	-0.485673
Non-operative	Sepsis	Sepsis with shock other than urinary tract ANZICS addition	503	0.353941
Non-operative	Sepsis	Sepsis of Urinary tract origin with shock ANZICS addition	504	-0.485673
Non-operative	Trauma	Head Trauma +/- multi trauma	601	0.369166
Non-operative	Trauma	Multiple trauma excluding head	602	-0.619483
Non-operative	Trauma	Burns ANZICS addition	603	-0.619483
Non-operative	Trauma	Multi trauma with spinal injury ANZICS addition	604	-0.619483
Non-operative	Trauma	Isolated cervical spine injury ANZICS addition	605	-0.619483
Non-operative	Undefined	No Diagnosis Entered	0	0
Post-operative	Cardiovascular	Dissecting/ruptured Aorta	1201	0.24349
Post-operative	Cardiovascular	Periph. Vasc Dis-No Graft	1202	-0.062337
Post-operative	Cardiovascular	Peripheral Artery Bypass Graft e.g. Fempop	1203	-0.768555
Post-operative	Cardiovascular	Elective AA	1204	-0.828717
Post-operative	Cardiovascular	Carotid Endarterectomy	1205	-1.019287
Post-operative	Cardiovascular	Valvular Heart Surgery	1206	-0.501745
Post-operative	Cardiovascular	Coronary Artery Bypass Grafts ANZICS addition: baseline modifier	1207	-7.246664
Post-operative	Cardiovascular	CABG but female	1207	0.861304
Post-operative	Cardiovascular	CABG but redo	1207	1.206335
Post-operative	Cardiovascular	CABG - each extra graft	1207	0.082575
Post-operative	Cardiovascular	CABG but emergency	1207	0.76644
Comorbiodities	Chronic	AIDS	0	1.024126
Comorbiodities	Chronic	Liver failure	0	1.13343
Comorbiodities	Chronic	Lymphoma	0	1.004806
Comorbiodities	Chronic	Metastatic cancer	0	0.885923
Comorbiodities	Chronic	Leukaemia	0	0.755685
Comorbiodities	Chronic	Immune suppressive disease	0	0.321419
Comorbiodities	Chronic	Immunesuppressive treatment	0	0.321419
Comorbiodities	Chronic	Cirrhosis	0	0.860462
Demographics	n/a	age < 60	0	-0.765009
Demographics	n/a	age < 65	0	-0.529345
Demographics	n/a	age < 70	0	-0.222009
Demographics	n/a	age < 75	0	0.107859
Demographics	n/a	age < 85	0	0.169567
Demographics	n/a	age >= 85	0	0.765707
Post-operative	Cardiovascular	Other Cardiovascular Diseases	1208	-0.258392
Post-operative	Cardiovascular	Dissecting Aortic Aneurysm	1209	0.965189
Post-operative	Cardiovascular	Ruptured Aortic Aneurysm	1210	0.24349
Post-operative	Cardiovascular	Aorto-femoral bypass graft	1211	-0.637542
Post-operative	Cardiovascular	CABG with valve repair/replacement	1212	-0.537793
Post-operative	Cardiovascular	Endoluminal Aortic Repair	1213	-0.828717
Post-operative	Gastrointestinal	GI Perforation/Rupture - Not Peritonitis	1401	0.488538
Post-operative	Gastrointestinal	GI Inflammatory Disease - Not Absess/Fistula Peritonitis	1402	-0.287223
Post-operative	Gastrointestinal	GI Bleeding	1403	-0.297464
Post-operative	Gastrointestinal	GI Obstruction	1404	-0.013338
Post-operative	Gastrointestinal	GI Neoplasm	1405	-0.149182
Post-operative	Gastrointestinal	Cholecystitis/cholangitis	1406	-0.755966
Post-operative	Gastrointestinal	Liver Transplant	1407	-1.282196
Post-operative	Gastrointestinal	Other GI Diseases	1408	-0.236372
Post-operative	Gastrointestinal	Fistula/Abscess surgery	1409	-0.254507
Post-operative	Gastrointestinal	GI Vascular ischemia resection surgery	1410	0.679961
Post-operative	Gastrointestinal	Pancreatitis	1411	-0.287223
Post-operative	Gastrointestinal	Peritonitis	1412	-0.287223
Post-operative	Gastrointestinal	Other GI inflammatory disease	1413	-0.287223
Post-operative	Gynaecological	Hysterectomy	1801	-0.466038
Post-operative	Gynaecological	Pregnancy related disorder	1802	-0.130586
Post-operative	Gynaecological	Other Gynaecological disease	1803	-0.130586
Post-operative	Haematological	Haematological disease	2101	0.407784
Post-operative	Metabolic	Metabolic disease	2201	0.407784
Post-operative	Musculoskeletal/Skin	Orthopedic surgery	1902	-0.130586
Post-operative	Musculoskeletal/Skin	Skin surgery	1903	-0.130586
Post-operative	Musculoskeletal/Skin	Cellulitis/soft tissue infection	1904	0.13398
Post-operative	Neurological	Intracerebral Haemorrhage	1501	1.064711
Post-operative	Neurological	Subdural/epidural Haematoma	1502	0.835429
Post-operative	Neurological	Subarachnoid Haemorrhage	1503	0.312849
Post-operative	Neurological	Laminectomy/spinal cord surg.	1504	-0.150739
Post-operative	Neurological	Craniotomy for Neoplasm	1505	0.051966
Post-operative	Neurological	Other Neurologic Disease	1506	0.335437
Post-operative	Orthopaedic	Hip or Extremity Fracture	1901	-0.508191
Post-operative	Renal/Genitourinary	Renal Neoplasm	1701	-0.631767
Post-operative	Renal/Genitourinary	Other Renal Diseases	1703	-1.422721
Post-operative	Renal/Genitourinary	Kidney Transplant	1704	-1.422721
Post-operative	Renal/Genitourinary	Genitourinary surgery/procedure	1705	-0.130586
Post-operative	Respiratory	Respiratory Infection	1301	-0.232717
Post-operative	Respiratory	Respiratory Neoplasm - Lung	1302	-0.113698
Post-operative	Respiratory	Respiratory Neoplasm - Mouth /larynx /sinus /trach	1303	-0.226492
Post-operative	Respiratory	Other Respiratory Diseases	1304	0.257491
Post-operative	Trauma	Head Trauma +/- multi trauma	1601	0.182766
Post-operative	Trauma	Multiple Trauma excluding head	1602	-0.508191
Post-operative	Trauma	Burns ANZICS addition	1603	-0.508191
Post-operative	Trauma	Multitrauma with spinal injury ANZICS addition	1604	-0.508191
Post-operative	Trauma	Isolated cervical spinal injury ANZICS addition	1605	-0.508191