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Chronic critical illness
Crit Care Clin 18 (2002) xi – xii
Preface
Chronic critical illness
David M. Nierman, MD, FCCM, FCCP Judith E. Nelson, MD, JD, FCCP Guest Editors
A growing population of patients survives acute critical illness only to become chronically critically ill, with profound debilitation and ongoing respiratory failure. Although prolonged dependence on mechanical ventilation is a defining characteristic, chronic critical illness (CCI) may be more appropriately viewed as a syndrome encompassing multiple characteristics including metabolic, endocrine, physiologic, and immunologic abnormalities. These derangements, initiated by an episode of sepsis, accompanied by dysfunction of various organ systems, and perpetuated by acquired morbidities, serve to slow or preclude recovery from a wide range of acute forms of medical, surgical, and neurologic critical illness. Care of the chronically critically ill is extremely challenging, protracted, and resourceintensive, requiring multidisciplinary expertise, substantial commitment on the part of caregivers, and weeks to months of hospitalization. Unfortunately, even with excellent care in specialized units in acute care hospitals, long-term acute care facilities or skilled nursing facilities, many of these patients continue to require mechanical ventilation and/or other forms of intensive support, with high rates of early mortality and extreme functional dependence. In this issue of Critical Care Clinics, a multidisciplinary group of experts addresses core issues for intensivists and others involved in the care of patients with CCI. The focus is specific, with emphasis on the emerging scientific understanding of distinctive features of this phase and the growing clinical experience with specialized models of care. Epidemiology, pathobiology, and pathophysiology are discussed, laying the foundation for articles about difficult clinical problems that arise commonly, including strategies for liberation from 0749-0704/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 0 7 4 9 - 0 7 0 4 ( 0 2 ) 0 0 0 1 7 - 9
xii
Preface / Crit Care Clin 18 (2002) xi–xii
mechanical ventilation, management of pressure ulcers and other wounds, delivery of complex nursing care, and integration of palliative care along with life-prolonging and disease-modifying treatment. Appropriate goals for care of the chronically critically ill, economic and human costs of treating these patients, and ethical issues are also addressed. CCI is a recent development, appearing in the wake of scientific and technologic advances in acute critical care. Much remains to be known about it; even an accepted definition of the term is still elusive. We hope this issue of Critical Care Clinics is a step forward, bringing together the most current information, ideas, and clinical experience, provoking dialogue, further research, and clinical initiatives. The true power of acute critical care will be harnessed only when we find better ways to care for those who are its product, the chronically critically ill. David M. Nierman, MD, FCCM, FCCP Judith E. Nelson, MD, JD, FCCP Division of Pulmonary and Critical Care Medicine Mount Sinai School of Medicine One Gustave L. Levy Place, Box 1232 New York NY 10029, USA
Preface
Chronic critical illness
David M. Nierman, MD, FCCM, FCCP Judith E. Nelson, MD, JD, FCCP Guest Editors
A growing population of patients survives acute critical illness only to become chronically critically ill, with profound debilitation and ongoing respiratory failure. Although prolonged dependence on mechanical ventilation is a defining characteristic, chronic critical illness (CCI) may be more appropriately viewed as a syndrome encompassing multiple characteristics including metabolic, endocrine, physiologic, and immunologic abnormalities. These derangements, initiated by an episode of sepsis, accompanied by dysfunction of various organ systems, and perpetuated by acquired morbidities, serve to slow or preclude recovery from a wide range of acute forms of medical, surgical, and neurologic critical illness. Care of the chronically critically ill is extremely challenging, protracted, and resourceintensive, requiring multidisciplinary expertise, substantial commitment on the part of caregivers, and weeks to months of hospitalization. Unfortunately, even with excellent care in specialized units in acute care hospitals, long-term acute care facilities or skilled nursing facilities, many of these patients continue to require mechanical ventilation and/or other forms of intensive support, with high rates of early mortality and extreme functional dependence. In this issue of Critical Care Clinics, a multidisciplinary group of experts addresses core issues for intensivists and others involved in the care of patients with CCI. The focus is specific, with emphasis on the emerging scientific understanding of distinctive features of this phase and the growing clinical experience with specialized models of care. Epidemiology, pathobiology, and pathophysiology are discussed, laying the foundation for articles about difficult clinical problems that arise commonly, including strategies for liberation from 0749-0704/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 0 7 4 9 - 0 7 0 4 ( 0 2 ) 0 0 0 1 7 - 9
xii
Preface / Crit Care Clin 18 (2002) xi–xii
mechanical ventilation, management of pressure ulcers and other wounds, delivery of complex nursing care, and integration of palliative care along with life-prolonging and disease-modifying treatment. Appropriate goals for care of the chronically critically ill, economic and human costs of treating these patients, and ethical issues are also addressed. CCI is a recent development, appearing in the wake of scientific and technologic advances in acute critical care. Much remains to be known about it; even an accepted definition of the term is still elusive. We hope this issue of Critical Care Clinics is a step forward, bringing together the most current information, ideas, and clinical experience, provoking dialogue, further research, and clinical initiatives. The true power of acute critical care will be harnessed only when we find better ways to care for those who are its product, the chronically critically ill. David M. Nierman, MD, FCCM, FCCP Judith E. Nelson, MD, JD, FCCP Division of Pulmonary and Critical Care Medicine Mount Sinai School of Medicine One Gustave L. Levy Place, Box 1232 New York NY 10029, USA