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.

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).

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.

 

 

References

Langlois, Jean A., Wesley Rutland-Brown, and Marlena M. Wald. "The epidemiology and impact of traumatic brain injury: a brief overview." The Journal of head trauma rehabilitation 21.5 (2006): 375-378.

 

Steyerberg, Ewout W., et al. "Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics." PLoS medicine 5.8 (2008): e165.

 

Stocchetti, Nino, et al. "Traumatic brain injury in an aging population." Journal of neurotrauma 29.6 (2012): 1119-1125.

 

Amacher, Loren A., and David E. Bybee. "Toleration of head injury by the elderly." Neurosurgery 20.6 (1987): 954-958.

 

Jamjoom, Abdulhakim, et al. "Outcome following surgical evacuation of traumatic intracranial haematomas in the elderly." British journal of neurosurgery 6.1 (1992): 27-32.

Oh's Intensive Care manual: Chapter 8 (pp.61)  Common  problems  after  ICU   by Carl  S  Waldmann  and  Evelyn  Corner