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critical disease; critical illness; critically ill patient; critical condition

Also see critical illness syndrome, critical care medicine & intensive care unit Etiology: - precipitated by clinical deterioration 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] Special laboratory: - 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] - critical illness polyneuropathy - critical illness myopathy - 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: - emergency department - intensive care unit - 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] - hypocaloric vs full enteric nutrition with similar outcomes (ventilator-free days, 6 month outcome & mortality) [1,7,16] - burns may be exception - 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] - oxygen therapy - similar outcomes with low normal 80 mm Hg vs high normal 96 mm Hg PaO2 [18] - 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]

Related

critical care medicine intensive care unit (ICU)

Specific

critical illness syndrome hypertensive crisis (malignant hypertension)

General

acute disease

References

  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: 22307571 - Griffiths RD. Nutrition for critically ill patients: How much is enough? JAMA 2012 Feb 22/29; 307:845 PMID: 22307570
  2. Boonen E et al. Reduced cortisol metabolism during critical illness. N Engl J Med 2013 Mar 19 PMID: 23506003 http://www.nejm.org/doi/full/10.1056/NEJMoa1214969
  3. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 19. American College of Physicians, Philadelphia 2012, 2015, 2022.
  4. Pandharipande PP et al. Long-term cognitive impairment after critical illness. N Engl J Med 2013 Oct 3; 369:1306 PMID: 24088092
  5. Adler SM1, Verbalis JG. Disorders of body water homeostasis in critical illness. Endocrinol Metab Clin North Am. 2006 Dec;35(4):873-94 PMID: 17127152
  6. Harvey SE et al. Trial of the route of early nutritional support in critically ill adults. N Engl J Med 2014 Oct 1 PMID: 25271389
  7. Arabi YM et al. Permissive underfeeding or standard enteral feeding in critically ill adults. N Engl J Med 2015 Jun 18; 372:2398 PMID: 25992505
  8. 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: 25665067 - Covinsky KE. The critical importance of functional status in critical illness. JAMA Intern Med. 2015;175(4):530. PMID: 25665038
  9. 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: 2677178
  10. 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: 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: 27380340
  11. 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: 29128300 - Van Dyck L, Casaer MP. Nutrition in the ICU: Sometimes route does matter. Lancet 2017 Nov 8 PMID: 29128299
  12. 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: 29384780 https://journals.lww.com/ccmjournal/Abstract/publishahead/Effect_of_Emergency_Department_and_ICU_Occupancy.96357.aspx
  13. 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. PMID: 29406182 http://bjanaesthesia.org/article/S0007-0912(17)54060-X/fulltext
  14. 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. PMID: 30504428 http://n.neurology.org/content/92/1/e9
  15. 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: 31826336 https://www.nejm.org/doi/10.1056/NEJMoa1911124
  16. 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: 31904995 https://www.atsjournals.org/doi/10.1164/rccm.201909-1810OC
  17. 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: 32250436 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2763718
  18. 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: 34463696 https://jamanetwork.com/journals/jama/article-abstract/2783810
  19. 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: 35041780 https://www.nejm.org/doi/10.1056/NEJMoa2114464
  20. Paton M et al. The effect of mobilization at 6 months after critical illness - Meta-analysis. NEJM Evid 2023 Feb; 2:EVIDoa2200234. PMID: 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: 36286256 https://www.nejm.org/doi/10.1056/NEJMoa2209083
  21. Herridge MS, Azoulay E. Outcomes after Critical Illness. N Engl J Med 2023; 388:913-924 PMID: 36884324 https://www.nejm.org/doi/full/10.1056/NEJMra2104669