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Patient Care in the Aftermath of Discharge from an ICU
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Am Fam Physician. 2000 Feb 1;61(3):805.
Mortality rates of patients discharged from intensive care units (ICUs) remain elevated for several years following the acute episode. Little research has been conducted on the complex physical, psychologic and social aspects of recovery from ICU admission. A review by Griffiths and Jones stresses the need for sustained expert support for discharged patients and their families.
Obvious issues for patients discharged from intensive care include the after-effects of the admitting illness or trauma and any resultant organ failure. Iatrogenic effects (e.g., nerve palsies, scarring from surgery and infusion sites, tracheal stenosis, osteoporosis and skin breakdown) may be severe. Patients may also experience significant joint stiffness, numbness, paresthesias, cardiac decompensation, disturbances in sleep pattern, alterations of taste and other physical and emotional problems. Disturbances of autonomic function are common, particularly postural hypotension.
Patients in intensive care can lose about 2 percent of muscle mass daily because of a combination of catabolism and neuropathic degeneration. A prolonged admission is likely to result in profound weakness and physical disability. Severe weakness and fatigue are the most common symptoms reported by patients following ICU care. Muscle weakness increases vulnerability to falling and difficulty in mobility and posture control. Families and nursing staff must be alert to these dangers and the attendant frustration for patients. Muscle weakness also contributes to poor cough reflex and difficulty in swallowing, resulting in impaired pulmonary protection and feeding problems.
Patients may appear completely oriented on discharge from intensive care and may seem to have good comprehension of and adjustment to their experience yet, after a few days, they recall little of their ICU stay. Psychologic symptoms similar to post-traumatic stress disorder are common. Patients report distressing memories and dreams, which often have a persecution theme. Symptoms are reported to be more severe in patients discharged from windowless ICUs. Psychologic symptoms may be exacerbated by physical symptoms, particularly weakness and change in appearance related to weight loss.
Symptoms persist for many months. Six months after discharge, nearly one half of discharged patients reported reduced social activity and increased friction with family members.
Early intervention using mobilization, counseling and support for patients and families is recommended. Family physicians should be prepared to encourage physical and psychologic recovery for patients and their families following discharge from intensive care. Providing opportunities to “debrief” patients and disclose symptoms attributable to stress may be as important as caring for the prolonged physical implications of intensive care.
Griffiths RD, Jones C. Recovery from intensive care. BMJ. August 14, 1999;319:427–9.
Copyright © 2000 by the American Academy of Family Physicians.
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