Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now, your host, Dr. Sergio Zanotti.
Speaker: We have made great advances in the field of critical care medicine.
Speaker: Without doubt, we have improved our ability to care for the sickest patients.
Speaker: To support patients who are critically ill with multi-organ failure is something we continue to improve at.
Speaker: Yet, we have much to learn in the journey survivors of the ICU have ahead of them as they leave the ICU and try to heal and return to their families and society.
Speaker: In today's episode of the podcast, we will discuss outcomes after critical illness.
Speaker: Our guest is Dr. Margaret Herrich, Professor of Medicine and Senior Scientist in Critical Care and Respiratory Medicine at the University of Toronto.
Speaker: Dr. Herrich is also Director of Critical Care Research, Director of the RECOVER program,
Speaker: and Clinical Director of the Grace Recovery Program for Chronic Critical Illness at the University Health Network in Toronto, Canada.
Speaker: It is a true honor to have her on the podcast to discuss such an important topic for our practices.
Speaker: Margaret, welcome to Critical Matters.
Speaker: Thank you so much, Sergio.
Speaker: It's a pleasure to be here.
Speaker: As we were discussing before we started recording, ICUs all over North America and the world probably are very focused on helping patients survive from critical illness.
Speaker: And often when somebody leaves after a couple of weeks, the ICU, there seems to be this sense of victory and triumph.
Speaker: And what we're learning these days is that there's still a very long road ahead of our patients.
Speaker: And there's a lot of challenges and probably there's a lot that we can do and a lot that we have to learn to make that journey a better one for our patients.
Speaker: So I felt this was an extremely important topic and I'm so happy that you, with all your expertise, are willing to share that with our audience.
Speaker: Margaret, maybe we could start with a little bit of a historical perspective.
Speaker: I know a lot of our field kind of starts with ARDS, the original description, and slowly it seems that over decades we evolved our understanding of what it really means to be an ICU survivor.
Speaker: Yeah, I mean, that's right, Sergio.
Speaker: I think that that's right.
Speaker: I think there were studies before ARDS where people were beginning to think a little bit about this, but I think that was really the genesis of a lot of the outcomes work.
Speaker: And it's interesting that...
Speaker: You know, the outcomes work really began as being very single system focused, worrying about or at least reflecting on what the pulmonary function outcomes could look like and really progressing then to more generic health related quality of life outcomes.
Speaker: And then really in the last year,
Speaker: 15 to 20 years, really drilling down on different domains of disability.
Speaker: And, you know, the seminal papers there that we mentioned in our review.
Speaker: And I like to mention the names of people because we have a lot of important people who've contributed very seminal observations.
Speaker: So the neurocognitive aspect of things really contributed by Mona Hopkins and her group.
Speaker: And the PTSD challenges really brought to the community through the work of Gustav Schelling and others.
Speaker: And gradually more and more people contributing
Speaker: very important observations and really with the culmination of understanding that there are really multi-dimensional morbidities and ever-growing morbidity counts really as we become more aware of this and more deliberately catalog all of the challenges that patients have and their families have and
Speaker: I think one thing that Ellie and I were trying to emphasize in our review as well is that it's just really bringing children in.
Speaker: And, of course, the health care team, that an episode of critical illness really is the starting point for a cascade of many events for lots and lots of people involved.
Speaker: And there's a really durable impact of this that may extend for years or decades after these events.
Speaker: So, yeah, we have we've done a lot of great work.
Speaker: There's no question our specialty has really done a lot of great work.
Speaker: But I think this may be one of the really important.
Speaker: important challenges in the next decades to come to really understand how we can mitigate this in real time in the unit and what might be modifiable or non-modifiable morbidities afterwards and how to really care for
Speaker: patients and families and children longitudinally, but frankly, also our health care team.
Speaker: And I think the post-COVID observations have really heightened the urgency of, you know, many of these issues.
Speaker: And you mentioned challenges and you mentioned COVID.
Speaker: And I think that none of our listeners obviously is alien to what 2020, 2021, and part of 22 meant for critical care all over the world.
Speaker: I mean, we talked a lot about COVID, but an emerging concern and challenges, long COVID, which may be something different, or maybe just part of the same discussion we're having.
Speaker: I want to hear your opinion.
Speaker: But
Speaker: Could you just mention what that really means?
Speaker: I guess one way of thinking about it is that we have the largest cohort of critical illness survivors at one time worldwide, and now we've got to figure out what to do with them, right?
Speaker: Yeah, no question.
Speaker: I mean, we really kind of deliberately landed on this statement because –
Speaker: I think it takes the outcomes work, which has really been sort of percolating in the literature for decades, to another level and to really the level of a public health, public policy, urgency, emergency.
Speaker: I might even use the word emergency because there are just so many people.
Speaker: affected and the cascade of events that we just sort of chatted about, about patients and families and children.
Speaker: Yeah, I mean, I think that...
Speaker: I think it's a long discussion about what long COVID really means, you know, because I think long COVID looks very different across this spectrum of severity of illness.
Speaker: And we're looking at that a bit in our Canadian National Study, CANCOVE, and I'm leading with my colleague here in Canada, Dr. Angela Chung.
Speaker: So Angela and I talk about this a lot, and lots of people in our community talk about this a lot, I think.
Speaker: the long COVID in the ICU folks is different.
Speaker: Um,
Speaker: I think there's an enormous overlap with what we already know in the post-ICU outcomes literature and this sort of overlapping construct of post-ARDS, post-sepsis, post-chronic critical illness, and the post-intensive care syndrome nomenclature put forward by Dale Needham.
Speaker: and others but you know I think there definitely is a unique contribution from COVID as well and I think it's going to take a while to really sort that out I mean there is a
Speaker: There is a very specific brain injury with COVID and renal injury and pulmonary injury that cardiac injury, you know, sort of multi-system injuries related to the ACE2 receptor sort of ubiquitous expression that I think is a bit different.
Speaker: But I think we are seeing so much overlap that it may be how we manage patients
Speaker: the morbidities in the longer term may look pretty similar to what we're trying to put together for post-ICU patients and families.
Speaker: And that in turn probably looks a lot like these historic, multidisciplinary, interprofessional models of rehab that most of us who do this work have adapted or adopted regularly
Speaker: that really began in the kind of pulmonary rehab, cardiac rehab literature.
Speaker: So just to kind of reference that history too, because it's really what people need and longitudinal care needs.
Speaker: a sense of connectedness, you know, whether that's through a navigator role, a nursing or other navigator role, but just continuity and education and advocacy, you know, sort of as basic principles for trying to address not only what long COVID will look like, but just, you know, sort of the more generic construct of post-critical illness outcomes.
Speaker: Absolutely.
Speaker: And I think that, as you mentioned, there might be some specific, unique aspects.
Speaker: But today we're going to focus on what's common to surviving critical illness and the journey post that.
Speaker: So maybe we could start or we could continue by diving into a little bit of...
Speaker: patient outcomes after critical illness, specifically thinking of three buckets of physical sequela, cognitive impairment, and mood and psychological impact.
Speaker: I think that's a good construct that we can use as a framework today.
Speaker: And why don't we start with some physical sequela that are common to many patients who survive the ICU that a lot of intensivists might not be thinking of as their patients leave the ICU?
Speaker: Yeah, sure, Sergio.
Speaker: I think...
Speaker: You know, I would always sort of put at the top of the list ICU acquired weakness and with that acquired or exacerbated frailty.
Speaker: So for your listeners who are maybe less familiar with ICU acquired weakness, this is a construct that's really emerged a lot in the last 15 to 20 years.
Speaker: But there are historic reports of this dating back to the early 80s.
Speaker: And actually, by some Canadian colleagues of mine, I'm really noticing a flaccid quadriparesis in the ICU.
Speaker: So what is this?
Speaker: It really is an injury to the muscle and to the nerve.
Speaker: And it's not just from immobility.
Speaker: I think it's an important issue.
Speaker: Clarification here that there is a certain degree of muscle injury that relates to mechanical unloading through immobility because we're sedating, we're paralyzing our patients.
Speaker: But these are discrete injuries to the muscle, characterized as a myosin depletion myopathy, and an injury to the nerve, characterized as an axinopathy.
Speaker: And these can occur separately, very commonly occur together.
Speaker: they really create an enormous burden of disability.
Speaker: And we know that ICU-acquired weakness increases time on the ventilator because it affects the diaphragm.
Speaker: And the diaphragm may be specifically vulnerable to these sorts of injuries because the diaphragm teleologically is a muscle that was never programmed to rest.
Speaker: It's our only muscle that never rests.
Speaker: We use it 24 hours a day, seven days a week.
Speaker: So, you know, and many weeks a year.
Speaker: So the ICU acquired weakness will prolong mechanical ventilation.
Speaker: So ventilator time, ICU length of stay, hospital length of stay.
Speaker: It's associated with an increase in ICU mortality, hospital mortality, one-year mortality,
Speaker: And maybe may result in durable disability for five to eight to more years and may not be wholly reversible.
Speaker: So it's quite a devastating complication.
Speaker: And I think there is.
Speaker: an assumption that with rehab, this will all get better.
Speaker: And I think it's very important for me to clarify that with your listeners, that certainly rehabilitation and early mobility can help.
Speaker: However, there can be a point of no return for every patient after they've been in the unit for weeks or months.
Speaker: Because, and this is some nice work from Samir Jaber,
Speaker: and others.
Speaker: Over time, the sarcomeres of the muscle may become fixed, and you actually will have an irreversible injury to the muscle, and the contractile force will be lost.
Speaker: Muscles may not necessarily regenerate or don't regenerate with the same degree of muscle bulk or contractile force.
Speaker: This is also work published by Jane Bade and Claudia DeSantos, who work here at the University of Toronto,
Speaker: in their own group collaboratively with our recover group.
Speaker: And there are lots of muscle groups around the world.
Speaker: There's a large muscle group in the UK.
Speaker: This is the, pardon me, the group who published the JAMA paper led by Zudin Puthachiri, Nick Hart, Steve Herridge.
Speaker: and others which showed this sort of relentless muscle loss during the first week of ICU.
Speaker: They were looking at quadriceps muscle.
Speaker: And Sandy Levine in his New England Journal paper in 2008 looking at the injury to the diaphragm.
Speaker: So I'm just referencing some and naming some individuals who've made some seminal observations here.
Speaker: And just to highlight, this can be a devastating, long-term, and sometimes irreversible situation
Speaker: disability, and it is linked to age.
Speaker: It's linked to ICU length of stay.
Speaker: It's linked to severity of illness.
Speaker: And there's a beautiful review on ICU acquired weakness led by
Speaker: led by Jesse Hall and JP Kress in the New England Journal.
Speaker: And so I refer your listeners to that excellent review.
Speaker: And we'll definitely link that in the show notes.
Speaker: Absolutely.
Speaker: Yeah.
Speaker: Yeah.
Speaker: Really drills down on that 100%.
Speaker: And
Speaker: And frailty too, you know, as sort of a slightly different construct, but frailty as something that's a very important negative prognosticator for outcomes in people who come to the ICU with this, and often it's exacerbated or acquired in the ICU, also an independent risk factor for all of these negative long-term outcomes that I've mentioned with ICU acquired weakness.
Speaker: Yeah.
Speaker: Absolutely.
Speaker: So that's a good place to start.
Speaker: Did you want me to focus on some other things or yeah, go ahead.
Speaker: No, and I was going to say that with ICU acquired weakness, it's almost like the tip of the iceberg, right?
Speaker: We started talking about this earlier, but then we started adding more and more layers, not only of understanding of that specific topic, but other problems.
Speaker: that our ICU survivors develop post the ICU stay.
Speaker: Are there any others that you want to mention in the physical consequences that might be of relevance before we dive into the cognitive area?
Speaker: Yeah, for sure.
Speaker: Again, you know, many people have published on these, so your readers can look at those for sure.
Speaker: And we articulated a few of these in our sort of original sort of one-year ARDS outcomes paper, actually, shockingly, 20 years ago now.
Speaker: But
Speaker: Things I like to highlight because they sometimes don't get quite as much attention.
Speaker: So with immobility, though, there's a lot of morbidity from contractures.
Speaker: In particular, frozen shoulders are very morbid.
Speaker: Some patients can develop heterotopic ossification, which is sort of an extraarticular bony deposition, again leading to a decrease in joint movement and disability.
Speaker: A lot of patients will have peripheral neuropathies, again related to
Speaker: nerve injury, but these can be pretty devastating and also lead to gait disturbances and disability.
Speaker: Some things that I really might highlight that often don't get to prime time are pressure injuries, which I think many of us in ICU might think just get better over time.
Speaker: These can be extremely morbid and can take a year or longer to heal, especially because they're often colonized with really pernicious, multiply drug-resistant organisms.
Speaker: And actually, the severity of pressure injuries and their duration, they are associated with one-year mortality.
Speaker: And this is a very seminal observation in the decubitus paper that was published recently.
Speaker: The other thing I might like to emphasize in addition to pressure injuries that people don't talk about enough, I think, is oral health.
Speaker: I mean, I've always been struck in our follow-up over the years by how much tooth loss and dental morbidity our patients have.
Speaker: And they don't talk about it.
Speaker: And maybe people think this is just normal.
Speaker: I think we can do a much better job with oral hygiene, tooth brushing.
Speaker: There's enormous dental loss and complex gingival disease, need for root canals.
Speaker: And depending on what country you live in and your own income issues, this can be an extraordinary burden and extremely expensive.
Speaker: And it really can go on for years as well.
Speaker: And I think it would be good to really highlight this.
Speaker: There's also vocal cord injury.
Speaker: I would just make the comment in our COVID cohort.
Speaker: And I think this may be due to proning.
Speaker: I've never seen so many tracheal injuries.
Speaker: We have a lot of people with tracheal stenosis, which has been documented by our group and other groups historically.
Speaker: But I think this may be a new and emerging, you know, getting back to my comment that we have this ever-increasing list of things to keep an eye on, may be related to a lot of recurrent and chronic proning that we may be creating in
Speaker: airway injuries that manifest you know months later as a tracheal stenosis and may go undiagnosed so a long list of a lot of things and and we tried to really detail and enumerate these ellie and i did in our paper so i might refer to your listeners to that as well for a more complete list
Speaker: Absolutely.
Speaker: And I think that what you mentioned about the tracheal injury is very interesting because it also makes me think immediately, Margaret, are there unique aspects of COVID as a disease or are there particular aspects of how we care for those patients that actually now are causing an increase in us diagnosing certain problems?
Speaker: Yeah, well, I mean...
Speaker: you know, for sure.
Speaker: I don't know.
Speaker: No, it's a question, a rhetorical question, I guess.
Speaker: It was a rhetorical question.
Speaker: Yeah, yeah.
Speaker: So I, yeah, like 100%.
Speaker: And I think I might just quickly say that the de-adoption of so many of our great
Speaker: principles that we've spent so many or standards of care that we spent so much time studying.
Speaker: I think we really need to have a hard and honest look at what the ramifications of those were for our patients, for sure, and families.
Speaker: Absolutely.
Speaker: So the other bucket we mentioned is cognitive impairment.
Speaker: And my understanding is that this is something that we have learned more recently, or at least after we were understanding about the...
Speaker: ICU acquired weakness, but it might have devastating effects on our patients.
Speaker: And especially if we don't talk to them about it, they don't realize that it's going on or that they can actually talk about it or try to seek help for it.
Speaker: Could you talk a little bit about this area?
Speaker: Yeah.
Speaker: Yeah, for sure.
Speaker: Well, at the beginning, I mentioned Mona Hopkins, who's really a very important figure in all of this and really put this whole issue on the map.
Speaker: So I really would want to publicly acknowledge Mona and her important work.
Speaker: She is the leader in this and everyone has followed her.
Speaker: She was the one who, in 1999, published a Blue Journal paper on cognitive outcomes in ARDS patients and really helped us to understand that these patients at one year, and now it's clear for many years, will have problems with ARDS.
Speaker: memory concentration, processing speed, and I have a lot of challenges with executive function, really the ability to multitask.
Speaker: And these can be really very devastating complications.
Speaker: I think this is one of the very invisible morbidities initially.
Speaker: Because in the ICU, you know, everyone is very excited that a patient can obey commands.
Speaker: And...
Speaker: I mean, while that can be very reassuring in the short term, it's really not going to disclose any of these higher cognitive or more integrative processes that really may be very compromised in our post-ICU patients.
Speaker: And in Mona's experience, and she's written a lot about this, and in her own experience and seeing ICU patients for a long time, often these cognitive problems, these cognitive sequelae don't really become evident until people try to resume their life again.
Speaker: And most usually try to go back to work and find that it is hard to, you know, their memory is not the same.
Speaker: It's hard to concentrate, hard to focus.
Speaker: They process at a more slower, you know, they process more slowly.
Speaker: And they really are having problems with,
Speaker: managing multiple tasks.
Speaker: And many of us have jobs that require very, very intact and high-level executive functioning.
Speaker: I would say as an intensivist, we're really taxed in that way enormously.
Speaker: And this can be a big barrier to return to work, as I mentioned, and can be very devastating for patients.
Speaker: I think that in my experience, this is just an anecdotal comment, that the higher functioning patients often...
Speaker: because they're really working at the limits of their cognition.
Speaker: Notice even a minor decrement in these abilities.
Speaker: And it can be extraordinarily distressing.
Speaker: And depending on the job, it really will work.
Speaker: it really will be a barrier.
Speaker: It's interesting in Mona's initial paper, a long time ago now, that the cognitive dysfunction was linked to hypoxemia.
Speaker: And
Speaker: And others now have really helped to create, you know, a list of risk factors that are also associated with cognitive dysfunction and things like being in deep coma, where we really have problems.
Speaker: an injury not just to the cortex but probably the white matter and a pruning effect related to a real change in exposure to external stimuli and all the various sedation and narcotic and anesthetic drugs.
Speaker: Just to your point earlier, Sergio, that we were running continuously for days and in many cases weeks.
Speaker: in some of our sickest COVID patients and just, you know, I mean, meeting all of the high-risk factors, the documented risk factors that we know are associated with long-term cognitive dysfunction.
Speaker: And a seminal observation from the Brain ICU group, the Vanderbilt group, that particular New England Journal paper published in 2013 led by Pradeck-Pendrup-Pondi and Wes Ely,
Speaker: You know, so many others, so many other leaders, Jim Jacks and others, who've, Tim Gerard, who've done a lot of important work, you know, showing not just delirium, but duration of delirium is an extremely potent determinant of long-term cognitive dysfunction.
Speaker: And we know in the COVID patients that they had a lot of very complex delirium.
Speaker: resort to polypharmacy often with sedation and narcotics, etc.
Speaker: to be able to vent them, to be able to manage them on ECLS and other things.
Speaker: Lots of robust literature that would make you expect or, you know, I mean, foreshadow what we're finding in the post-COVID people, that we were doing all the things that we know hurt the brain.
Speaker: And these are the consequences.
Speaker: Absolutely.
Speaker: And I'm always struck when we talk about cognitive impairment by just one case of a family friend who was older, but extremely functional, recovered from the ICU.
Speaker: Everybody was elated and it seemed he was fine, went back to run his business and six months later was bankrupt.
Speaker: And now connecting the dots, obviously, there probably was significant functional issues that were not recognized, were not addressed.
Speaker: Right.
Speaker: And this is not, I think, an uncommon story, unfortunately.
Speaker: Yeah, absolutely.
Speaker: And.
Speaker: And I think the other just along the, I'm so sorry to hear about your family friend.
Speaker: I, yeah, lots of stories like that, that so many of us in the outcomes world have heard in our clinics and indirectly.
Speaker: But I think there's just such a key issue that people should be really counseled not to try to return to work too early.
Speaker: And to really try to understand where they're at so that we can try to mitigate some of these disastrous consequences.
Speaker: Many people will have some, you know, improvement over time.
Speaker: There's no clear intervention at this moment, although, you know, Jim Jackson's working very hard on this in the brain ICU group in particular at Vanderbilt.
Speaker: But, you know, just even just trying to protect patients from themselves, you know, trying to get back to normal, trying to rush back to work, trying to put this horrible life event behind them.
Speaker: I see this a lot.
Speaker: And, you know,
Speaker: and really try to caution people and try to protect them from going back to work too early.
Speaker: One, because...
Speaker: I don't think it's good for their colleagues to see that maybe they're not functioning at the same level.
Speaker: And that creates its own problems at work, problems with discrimination, or they're trying to take on too much responsibility and truly are not able to with sometimes disastrous consequences, as you've just outlined.
Speaker: So I think this is an important role for the follow-up clinic or longitudinal follow-up care.
Speaker: to or educating primary care physicians because these clinics are not disseminated around the world to educate people about how to advise patients and families after this and maybe advocate for disability or rationale for being you know needing more recovery time I think if you've never
Speaker: known someone who's been in ICU or you don't understand what it looks like, I think people, when they come home, everyone around them figures they'll be fine in a couple of weeks.
Speaker: And of course, this is never the case.
Speaker: It's more like a year.
Speaker: And I've spent a lot of time writing letters advocating for disability with insurance companies, disability issues.
Speaker: And it's really tough.
Speaker: There's not a lot of understanding about this.
Speaker: And that translates into not a lot of work accommodation, unfortunately.
Speaker: Absolutely.
Speaker: And the third bucket I wanted to comment before we move on
Speaker: which obviously also is extremely important, is the mood disorders, psychological impact, or mental health disorders that are very common in the ICU in general for people who have worked in the ICU at COVID, but also for our patients.
Speaker: Could you just comment some of those aspects, Margaret?
Speaker: Yeah, for sure, Sergio.
Speaker: Maybe I'll just, I'll start with the patients and then maybe just comment briefly on the healthcare workers, because I think that's important too.
Speaker: So as I started off by saying that Gustav Schelling in his paper in 1998 said,
Speaker: I'm just highlighting the authors and the papers because these papers are a long time ago.
Speaker: And still, I think, Sergio, it may be some of your listeners or certainly many of our colleagues are really unaware of this robust literature that's decades old that Ellie and I were really trying to give a historic perspective on just to underline, like, we know this and we all should know this.
Speaker: So he really put PTSD on the map, and I think people at the time were shocked by it.
Speaker: Maybe in disbelief, but it's a very robust finding.
Speaker: As are anxiety problems.
Speaker: as is, pardon me, depressive symptoms.
Speaker: We've learned over the years that the depressive symptoms, and many people have published on this, many different groups.
Speaker: The Vanderbilt group has Mona's group.
Speaker: Our group in Toronto has Dale Needham's group.
Speaker: Hopkins has...
Speaker: Dimitri Davido, Joe Benvenu, who work at the Hopkins Group or have moved to other places now, Dimitri has published a lot on this topic, Jim Jackson recently, too.
Speaker: Really prevalent depressive symptoms, major episodes of depression.
Speaker: There's an emerging literature on suicidality.
Speaker: Shannon Fernando, a Canadian colleague in a recent JAMA paper published on suicidality.
Speaker: We know that there are challenges with substance misuse.
Speaker: So these are really big deals.
Speaker: And unfortunately, for a lot of the patients,
Speaker: They're ashamed of this.
Speaker: They're ashamed to talk about it.
Speaker: They've had the PTSD has been linked to restraint use in the ICU.
Speaker: Getting back to some of your earlier comments, things we can do.
Speaker: We should not be tying people down.
Speaker: There's some suggestion, although it's inconsistent, that polypharmacy and running these continuous sedation infusions or drug infusions may be associated with that, but it's equivocal.
Speaker: Some studies have shown that.
Speaker: The Brain ICU New England Journal paper did not demonstrate that, at least with cognition and mood disorders.
Speaker: But these are ways we can mitigate that, but they're devastating.
Speaker: The delusions that patients have as part of delirium in the ICU are very disturbing.
Speaker: Many of us who do follow-up have had patients talk a lot with us once they know and trust us that they have...
Speaker: they are convinced, tragically, that they've been sexually assaulted in the ICU.
Speaker: So many stimuli in the ICU are distorted and misperceived in the context of delirium in a very kind of persecutory way.
Speaker: So the difficult to insert femoral vascaf
Speaker: Maybe construed as sexual assault or the insertion of rectal tubes similarly.
Speaker: Being tied down, absolutely.
Speaker: It's not hard to imagine how people feel they've been, they are being tortured and held in places against their will.
Speaker: So I think we have a lot of work to do in that, and it's always very disturbing and continues to be very disturbing for those of us who do follow up to listen to these stories.
Speaker: They are not one-off stories.
Speaker: They are robust stories.
Speaker: I've been listening to stories like this for decades in our own work here in Toronto.
Speaker: So very important to emphasize that and to think about ways we can improve it.
Speaker: I might just finish by just saying the healthcare workers we know now get really sick.
Speaker: And I think that this kind of, if I can be candid, and it's okay here.
Speaker: Absolutely.
Speaker: You might disagree with me, but I think this kind of hero archetype, the intensivist as the hero archetype, only does our profession a disservice.
Speaker: We are people.
Speaker: And after COVID, we all have our own devastating stories and experiences.
Speaker: Many people have been challenged by their own mood disorders, mental health issues.
Speaker: I think, and we sort of tried to highlight this in the paper too, that
Speaker: it has its own effect on those of us who do this work.
Speaker: And we need to look after ourselves and our community as well and acknowledge, I think, I hope, that what we do changes us too.
Speaker: And we need to...
Speaker: kind of acknowledge that and be honest about how difficult this work is.
Speaker: As rewarding as it is and how much, you know, we all love doing it and making a difference, we pay a price for doing it.
Speaker: And I think it's important to be able to talk openly and honestly about that.
Speaker: I couldn't agree more.
Speaker: And I always say that we don't need another hero.
Speaker: We need great teams and a system that works, right?
Speaker: And that's what should be, I think, valued, praised, as opposed to somebody who's been on for 48 hours.
Speaker: That is not really what we need, like you said.
Speaker: So those are all great points.
Speaker: And
Speaker: And quite humbling.
Speaker: And I would hope that our listeners think about these issues with a lot more compassion and empathy towards our patients as we care for them in the ICU.
Speaker: We talked a little bit about age and length of ICU stay as obviously important risk factors.
Speaker: Could you just give us a brief summary in terms of what are some of the risk factors that we know today, modifiable and non-modifiable, for all these post-ICU disabilities?
Speaker: Wow.
Speaker: Well, that could be his own podcast, Sergio.
Speaker: So maybe we just hit on the most important ones.
Speaker: Yeah.
Speaker: Let me just give you, I can give you sort of the highlights or things that I always try to teach when I'm attending myself and I try to highlight for our group.
Speaker: Yeah.
Speaker: I think what I always say to people when I'm working with the team is it's so important that, and I guess we tried to emphasize this too, that we really do embrace the continuum because everyone had a really important history before they came to the ICU.
Speaker: And the history may be that they were young and entirely healthy, but that's extremely relevant because that person has tons of reserve when they come.
Speaker: And that changes how you...
Speaker: I think your attitudes about how extensive your, I don't want to use the name of extensive, but the sort of extreme levels of care that you may wish to expose that patient to.
Speaker: How about I express it that way?
Speaker: But things that I really think are important to emphasize maybe for the listeners here,
Speaker: and this is some very nice work done by Lauren Ferrante and others, you know, the trajectory that someone's on before they come to the ICU is extremely important.
Speaker: And we often don't take a careful enough history because there's a lot of richness there in terms of prognostication.
Speaker: Not just older patients, but patients who are in declining health,
Speaker: patients who have acquired important frailty, patients who've had multiple hospital admissions leading up to kind of a final decompensation and they're in the ICU.
Speaker: You know, patients who are very comorbid, you know, they come to you with very limited reserve, whether that's neurocognitive reserve, they're beginning to show early signs of dementia, or, you know, they've got some underlying pulmonary or cardiac or renal disease, you know,
Speaker: or you know they're they're bed bound at home literally or in an institution the pre-icu trajectory is extremely key there's no doubt
Speaker: I would say the other issue too is that people get very upset when you talk about age, that it seems discriminatory, but it's not.
Speaker: The reason why age is in every prognostic model is for a good reason, because we all lose organ reserve with age.
Speaker: And it's part of normal aging, normal senescence that we lose organ reserve.
Speaker: And that is why age does matter.
Speaker: I mean, you know, I don't have the same reserve I had when I was, even though I am fortunate to be in good health, that I had 20 or 30 years ago.
Speaker: This is normal.
Speaker: And I think that this is important to keep in mind.
Speaker: I mentioned age, trajectory.
Speaker: I mentioned frailty is enormously important.
Speaker: and those are factors coming into the ICU for sure.
Speaker: In the ICU, I think that there's a robust literature from many groups.
Speaker: I like to highlight the French group, the Frog ICU group, our own recover groups contributed to this.
Speaker: Those who've published a lot on chronic critical illness, Judy Nelson, Shannon Carson, Terry Huff,
Speaker: Chris Cox, there are many, many leaders in this area have really helped to highlight, and in this Provence study that was led by Terry Huff, that the longer you spend in the ICU, the more trouble you're in.
Speaker: So I think that's an important piece for your listeners, that no one...
Speaker: No one is getting better weeks into the ICU.
Speaker: They might survive the unit, but what they definitely are accruing over time is disability.
Speaker: They're accruing physical disability, you know, the neuropsychological disabilities that we've already talked about in this podcast.
Speaker: And there's a huge cost to this.
Speaker: And we know from all of these studies that I've mentioned that each decade of age,
Speaker: Each week you spend in the unit, after about two weeks, you are going to have more and more disability.
Speaker: And it's not just that.
Speaker: It's that at one year, you're going to have an increase in your one-year mortality.
Speaker: So I really, one thing we were advocating for in the paper, and maybe, you know, it's controversial for some, but that it's literature-based, is that really after a couple of weeks, you know when someone's in trouble as an experienced intensivist.
Speaker: And I think it's really important to begin to have weekly discussions about
Speaker: about goals of care and just educating patients and families about disability, about accruing mortality risk, and really about all of the challenges that people may face.
Speaker: That's not to say that people won't want to take that on, but I think it's very important to be very transparent about what's happening.
Speaker: and that people have declared themselves as having very complex chronic critical illness.
Speaker: And there's a lot of morbidity and mortality and change in disposition that's associated with that and wanting to be really honest about living a life that looks like that.
Speaker: And depending on the health care system you're in, you know, dealing with an enormous cost.
Speaker: for the ICU care.
Speaker: This would not be the case in Canada, but in many countries.
Speaker: And then being disabled and unable to work on the back end of that with an enormous medical debt.
Speaker: So I think just having an honest discussion about that is something that I think we need to have a bit of a change in focus even during the acute ICU stay.
Speaker: I agree.
Speaker: And perhaps step number one in any new challenge or problem is awareness and understanding.
Speaker: But perhaps right after that, step number two for clinicians is to be familiar with the data and what really happens to patients and to share that information.
Speaker: in a way that families and patients can really understand what we're talking about weeks and weeks after ICU care.
Speaker: I think that's a great point.
Speaker: We talked a lot about patients, Margaret, but there are also co-survivors.
Speaker: There are family members and caregivers that also have significant impact post-ICU care.
Speaker: Could you just comment very briefly, and I know we're coming up on time, on some of the caregiver outcomes or family outcomes, and then we can maybe talk about some interventions and a call to action.
Speaker: For sure.
Speaker: Yeah, so I'm here representing both my colleague, Dr. Ellie Azoulay, and Ellie is really one of, if not the international expert in this area.
Speaker: So I would really want to couch my comments in that.
Speaker: We do some work too, and many others do, but Ellie is really the authority.
Speaker: I think it's important, and I love that you use the term co-survivors, Sergio.
Speaker: I think that's a really wonderful way to think about it.
Speaker: And I think it really is increasingly important to report and study dyads that we really acknowledge that patients have families like the pediatricians always have, but we're sort of a little bit behind in catching up in.
Speaker: The families suffer a lot.
Speaker: And I think, again, just getting back to your earlier comment on COVID, having the families away from the bedside was devastating.
Speaker: And Ellie and his colleague in Paris, who's also a leader in this area, Nancy Kentish Barnes, have published a lot on COVID recently about the isolation, especially how devastating that has been at the end of life.
Speaker: and the loss of sort of those final treasured moments at the end of someone's life, a family member.
Speaker: The families become mentally ill.
Speaker: And I think people find that hard to, people, I mean colleagues, find that really hard to accept.
Speaker: I would just say that from my own experience.
Speaker: I think historically we have really characterized families as
Speaker: Difficult.
Speaker: I'm sorry to use these words, but we've all heard them.
Speaker: Difficult, crazy, insane, you know, losing it.
Speaker: They can't cope with it.
Speaker: They don't get it.
Speaker: Like very hurtful, pejorative, critical comments of the family.
Speaker: And I think in my own practice as an intensivist and as a teacher, when I'm at the bedside, I...
Speaker: I mean, I'm not here to be self-righteous.
Speaker: I'm really here to be teaching or messaging that we need to show more compassion for the families.
Speaker: Sorry, they're going through the worst experience of their life.
Speaker: Most would characterize it as such.
Speaker: And not everyone is built for this kind of unremitting, high-level stress and uncertainty.
Speaker: And, you know, they just can't sublimate it in the same way.
Speaker: And we just expect people to behave themselves, to, you know, just agree with what we're saying and be calm and accepting.
Speaker: I mean, this is just not realistic.
Speaker: And it's really not fair.
Speaker: And I really, I think we can, one thing I hope our community can work on is being,
Speaker: less judgmental and more compassionate and definitely not endorsing of these sorts of pejorative, really harsh and cruel things that we say about the families all the time when you really listen for them.
Speaker: I think that's a great point.
Speaker: You've got to really stop that.
Speaker: You've got to really stop that.
Speaker: Yeah, one of the things, Margaret, that I have worked on as I've developed more white hair and reflected more on my career is when somebody talks to me or they sign out to me or the nurse talks about a...
Speaker: difficult family, I would kind of re-challenge them and say, maybe it's not a difficult family, but a family in a difficult position.
Speaker: Or maybe it's not a crazy family, it's a family in a crazy situation.
Speaker: And we all have seen this, when we become the family or we become the patient, we're no different, right?
Speaker: And it just has to do with everything that's going on.
Speaker: And like you said, being more compassionate and understanding
Speaker: I believe is extremely important.
Speaker: So I think that's a very, very valuable point.
Speaker: And as we move towards the closing, like you said, this is a topic that we're just scratching the surface, but there's a lot to learn, a lot to discuss.
Speaker: But what are some things, Marga, that we could do today to move the needle for our ICU survivors and their families?
Speaker: Well, I think...
Speaker: First of all, let me just say, Sergio, I really loved how you just said that you reframe this discussion about the families with your colleagues.
Speaker: I think it's a very wonderful way of reframing that's not judgmental also of their behavior.
Speaker: I just wanted to say I loved how you just phrased that.
Speaker: That was just great.
Speaker: Yeah.
Speaker: Well, I think one way to begin is what you're doing and others are doing is to try to disseminate and educate and to demystify what's going on and to not make it seem like it's an indictment of our specialty because it isn't.
Speaker: We're learning.
Speaker: You're right.
Speaker: We have a lot to learn and we have a lot to learn about ways that we can mitigate all of this.
Speaker: So,
Speaker: I think beginning with education and honesty and humility about what we're doing and, you know, really moving beyond saving a life.
Speaker: It has got to, we've got to, you know, examine this much more deeply and much more longitudinally.
Speaker: and maybe multidimensionally, maybe I would say that.
Speaker: I think outside of education, which is a great place to start, is...
Speaker: I do think we need some way to create pathways for these patients and families.
Speaker: And not every system is even amenable to that.
Speaker: Depending on the health care system you work in, it is really so compartmentalized and politically so, structurally so, that it may be very difficult to create continuity and to create pathways for these patients.
Speaker: In those systems in which it's possible, I think we really should move towards mandating that.
Speaker: This is possible in Canada.
Speaker: I think it's possible in single-payer systems because they, you know, I think that the health policy people can see the merits in this.
Speaker: And these won't necessarily be high-cost endeavours.
Speaker: Lots of people are working on interventional studies.
Speaker: Within the ICU, the whole early mobility movement is trying to understand how that can, you know, mitigate disability.
Speaker: The results are a bit equivocal.
Speaker: The most recent important teams, a study led by Carol Hodgson, unfortunately did not show
Speaker: There may be reasons for that methodologically, but it is a bit of an equivocal literature, getting back to what I was saying earlier on, that a lot of these injuries may not be wholly remediable or reversible.
Speaker: But understanding things already, you know, if you look to the A to F bundle, which some people are critical of, but I think it's a reasonable touchstone and kind of reminder of things that really we should try to do.
Speaker: And we de-adopted in COVID and we've seen the deleterious consequences of that.
Speaker: Things as simple as
Speaker: Also, monitoring or observing good glycemic control.
Speaker: We know, and this is work from Greet Vandenberg, not just her historic paper on tight glycemic control, but JAMA publication looking at tight glycemic control in children and how that mitigates cognitive dysfunction.
Speaker: I think...
Speaker: And triglycemic control can really mitigate some of these peripheral nerve and central nervous system issues.
Speaker: Hypoxemia, I mentioned in from Mona's work, you know, trying to mitigate delirium, again, a potent risk factor for cognitive dysfunction.
Speaker: Mood disorders, you know, not having people on polypharmacy, trying to have people awake so that we can reorient them and keep them connected in some way so they don't have these really injurious delusions.
Speaker: Don't tie people down.
Speaker: You know, I mean, these are things we can do now.
Speaker: In the longer term, the post-ICU, well, that's its own maybe chapter in discussion, but I think still working on understanding how much of the brain injury in the longer term can be mitigated, how much of the muscle injury can be mitigated.
Speaker: I think the benefit of the long-term follow-up right now is education, advocacy, continuity, helping in return to work, these sorts of things.
Speaker: And I think one of the most powerful aspects of suffering post-ICU, especially the psychological aspect of the cognitive, might be the isolation that people who suffer it, where it's a patient or a family member feel that
Speaker: in terms that this is only happening to them, which is a common theme in mental illness, right?
Speaker: And by educating, explaining that these things might occur, where to maybe seek some help, and realizing that these are common events that happen to a lot of people, and normalizing them as problems that need to be discussed, I think is also something where there's, from my perspective, plenty of opportunity in the ICU practice.
Speaker: Yeah, it's a great point.
Speaker: I think one thing that we really can mitigate in the longer term are the mood disorders.
Speaker: And I would really emphasize that, that the patients need us to advocate for access to mental health care after they leave the ICU.
Speaker: And you're right, normalize it so people don't feel so stigmatized and they'll be open to
Speaker: sorry, receiving this and pursuing it.
Speaker: Totally agree.
Speaker: And it's a great point, Sergio.
Speaker: Thank you.
Speaker: So I would like to close the podcast, Margaret, with questions that we ask our guests just to tap into their wisdom that are not related to the topic that we just discussed.
Speaker: Would that be okay?
Speaker: course sure no problem so the first question relates to books and I just want to know are there any books that have influenced you significantly or books that you have gifted often to other people oh um well I don't know it might um
Speaker: It might sound a bit weird.
Speaker: I mean, maybe I'll speak more personally that I am somebody who tends to read a lot of fiction.
Speaker: I read fiction that is about...
Speaker: human relationships because I think a lot about relationships in the ICU as an intensivist and we're exposed a lot to and exposed isn't the word I want to use we are enormously privileged to be welcomed into the or be allowed to have a look at someone's life
Speaker: at a moment when people are so exquisitely vulnerable.
Speaker: And so I read a lot about relationships and people and what people are going through.
Speaker: So I'll tell you one of my favorite authors in this way is Anne Patchett.
Speaker: She's an American author.
Speaker: And she writes a lot about complex people and complex relationships.
Speaker: And I guess I'm drawn to that because that's sort of the nature of the work that we do.
Speaker: Absolutely.
Speaker: And so that's what I do.
Speaker: That's what I read, actually.
Speaker: Love it.
Speaker: I'm a nonfiction reader, but I do read fiction because I do believe that in terms of enhancing our empathy, great fiction writers really understand human connection, human emotions and human behavior.
Speaker: And I agree 100% with what you said, Margaret.
Speaker: To be at somebody's bedside when they're dying and their family is around them is a privilege.
Speaker: And it's something that I think we should never lose sight of.
Speaker: And we should always look in awe because...
Speaker: It's one of the things that we don't fully understand.
Speaker: But you're right.
Speaker: I mean, it's all about that very intense human connection at a very vulnerable point.
Speaker: And we can make it a lot worse.
Speaker: We can make it a little bit better.
Speaker: And I think that we would all agree that we want to make it a little bit better.
Speaker: So definitely we'll add some Ann Patchett books and I'll definitely look to read one of them, see how I enjoy them.
Speaker: I'll let you know.
Speaker: Yeah.
Speaker: The second question is, is there something you believe that most people don't believe or don't behave like they believe can be in medicine or just in life in general?
Speaker: Wow.
Speaker: Um, well, I don't know.
Speaker: Um,
Speaker: That's a very, very deep and interesting question.
Speaker: I'm not even sure how to answer it.
Speaker: This is what, I mean, I'm not sure this is like a perfect answer to this question, but something maybe I've learned over the years.
Speaker: But some of the, I believe that people really are capable of
Speaker: a lot of, like really a lot of kindness.
Speaker: And that the kindness that you can see can be very unexpected and you see it in unexpected places.
Speaker: And that you can learn a lot about kindness.
Speaker: I think about this all the time when I'm in the unit.
Speaker: I think a lot about kindness in ways that people don't really acknowledge very frequently.
Speaker: So I look, I'm often so struck by this, like we have these patient attendants here in our ICU.
Speaker: Or, you know, I look at the kindness and how they carefully move patients who are often in such bad shape, you know, with these injuries and they're cachectic, etc., and show so much compassion and kindness as the nurses are washing them.
Speaker: And people don't even acknowledge this.
Speaker: But they're caring.
Speaker: And I see so much kindness in the people who clean our ICU.
Speaker: Most people don't even know their names.
Speaker: But they know the families.
Speaker: And they are there every day talking with the families and showing support.
Speaker: And I'm always so struck by a lot of our nurses who will say to me, well, Mark, I'm just going to give this person a spa night tonight.
Speaker: And they bring in toiletries.
Speaker: and they wash hair or put lotion on, and how patients in follow-up
Speaker: I'm highlighting these groups because patients in follow-up tell me this, you know, how much it meant for someone to move them so gently when they were in so much pain or the cleaning staff became friends with their family member or the night that the nurse just spent the night, like they were kind of weaning, kind of stable more, and there weren't acute issues, but the nurse just kind of comforted them and showed them so much kindness and
Speaker: I mean, I think a lot about that.
Speaker: So I don't think that's a unique observation, but I think that so many people are capable of so much kindness that maybe what I think people don't understand, to get back to the original question, is the lifelong impact, some of these extraordinarily kind actions, which some people might think are mundane, how profound the impact of these actions are on people,
Speaker: in this most vulnerable state of critical illness and how meaningful they are.
Speaker: I think that's the perfect answer, Margaret, and especially...
Speaker: The negativity that is fed to us through new cycles, through what's out there, I think makes us believe that there's so much wrong with the world, yet your observation that human beings not only have an enormous capacity for being kind, but we can find it.
Speaker: right around the corner where we work, right?
Speaker: We just have to look for it and find it.
Speaker: And the impact that a simple act of kindness can have on our human being is enormous.
Speaker: And we should, I think, not only value and embrace that, but look for it and try to replicate that.
Speaker: So I think that's the perfect answer, the perfect place to stop.
Speaker: I want to thank you for all your amazing work, for a beautiful review article that will link with other, obviously, literature that you mentioned.
Speaker: And more importantly, thank you for giving us your time today, Margaret.
Speaker: I hope to have you back.
Speaker: And there's a lot of topics that we can dive deeper and talk about as we learn.
Speaker: And once again, thank you so much.
Speaker: Thanks so much.
Speaker: Really nice to meet you, Sergio.
Speaker: Nice to chat with you.
Speaker: Thanks for your comments.
Speaker: And, you know, thanks for the opportunity to share some of these thoughts with your listeners.
Speaker: Thank you.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound's transforming the way critical care is provided in hospitals across the country.
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