Persistent inflammation, immunosuppression, and catabolism and the development of chronic critical illness after surgery

Abstract

As early as the 1990s, chronic critical illness, a distinct syndrome of persistent high-acuity illness requiring management in the ICU, was reported under a variety of descriptive terms including the "neuropathy of critical illness," "myopathy of critical illness," "ICU-acquired weakness," and most recently "post-intensive care unit syndrome." The widespread implementation of targeted shock resuscitation, improved organ support modalities, and evidence-based protocolized ICU care has resulted in significantly decreased in-hospital mortality within surgical ICUs, specifically by reducing early multiple organ failure deaths. However, a new phenotype of multiple organ failure has now emerged with persistent but manageable organ dysfunction, high resource utilization, and discharge to prolonged care facilities. This new multiple organ failure phenotype is now clinically associated with the rapidly increasing incidence of chronic critical illness in critically ill surgery patients. Although the underlying pathophysiology driving chronic critical illness remains incompletely described, the persistent inflammation, immunosuppression, and catabolism syndrome has been proposed as a mechanistic framework in which to explain the increased incidence of chronic critical illness in surgical ICUs. The purpose of this review is to provide a historic perspective of the epidemiologic evolution of multiple organ failure into persistent inflammation, immunosuppression, and catabolism syndrome; describe the mechanism that drives and sustains chronic critical illness, and review the long-term outcomes of surgical patients who develop chronic critical illness.

Multiple organ dysfunction after trauma

“…2-10) days and 24⋅0 per cent of all MODS deaths occurred within the first 48 h. For survivors, the median time with MODS was 10 (i.q.r. [5][6][7][8][9][10][11][12][13][14][15][16][17] days. In total, the 245 patients with MODS used 2656 critical care bed-days and spent 5872 days in hospital.…”

“…The calibration and goodness of fit of the logistic regression models were evaluated using the χ 2 Hosmer-Lemeshow (HL) test, and model discrimination was assessed by means of area under the receiver operating characteristic curve (AUROC). Correlations Duration of critical care stay (days)* 3 (2-5) 7 (4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14) 20 (16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27) 36 (32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47) 11 (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)…”

“…As early‐phase management strategies such as damage control resuscitation have been introduced and more injured patients are surviving to reach critical care, the nature of MODS appears to be changing. Reports of differences in patterns of evolution, severity and outcome are challenging the previously accepted clinical concepts of ‘early and late onset’ or bimodal peaks of MODS. Determining the incidence, pattern and outcomes of MODS in the modern era may help to identify therapeutic opportunities and inform study design for future research.…”

Seven Deadly Sins of Nutrition Therapy in Critically Ill Patients

“…It is important to bear in mind that critical patients go through periods of different hemodynamic, metabolic, and hormonal requirements and that the planning of macronutrient and micronutrient goals must undergo revision. 15,50 Pride, as a rule, is incompatible with intensive care.…”

Inflammation and disease: Modelling and modulation of the inflammatory response to alleviate critical illness

“…However, even these more realistic experimental models do not necessarily consider chronic disease burden in addition to the infection or a traumatic injury. Moreover, aging – and the associated phenomenon of “inflammaging” – further complicates diagnosis and therapy of critical illness in the elderly [37–39], though computational modelling of sepsis has been carried out using data from both small- and large-animal models of sepsis as well as studies involving aged animals [40]. …”