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Surviving the ICU Does Not Mean That the War Is Over

2013; Elsevier BV; Volume: 144; Issue: 1 Linguagem: Inglês

10.1378/chest.12-3091

1931-3543

Gustav Schelling, Hans‐Peter Kapfhammer,

Cardiac Arrest and Resuscitation

Toward the end of the 1990s, we had a young man in the ICU who was a survivor of severe ARDS. He had spent weeks on extracorporeal membrane oxygenation, he survived several episodes of septic shock, had multiple organ failure, and it took months to wean him off the ventilator. Given his severe course of illness, he had made an excellent recovery. He had no evidence of cognitive impairment, appeared to be oriented, and seemed to have some understanding of what had happened to him. He knew where he was and that his long-term prognosis was good. His family was happy and the relief that he survived his deadly illness was seen on their faces. The young man should have been content, too. Yet, he wasn't. He appeared to be tense and anxious; he looked around the room like somebody awaiting a next strike of disaster. Communication with him was difficult; he was monosyllabic, and he appeared wary, but was definitively not delirious. We did not know what to make of his symptoms and behavior. We thought of this young man frequently. Critical illness is a highly complicated puzzle. Could it be that we were missing a piece? We talked to him again, explaining that his illness was nearly over and that we knew that his chances of an almost complete recovery of pulmonary function were good. We asked him if he had any remaining questions, anything he wanted to know about the course of critical illness he had survived. He paused, but finally asked, “Is the war over?” He then started hesitantly to describe horrible scenes from an apocalyptic warfare: His family was killed, he was in terrible pain from injuries, he could not breath because he was covered with rocks from explosions, he was naked and cold, flashes were all around him, the imaginary enemy had hogtied him, and he was tortured time and again. Worst of all, the images tended to come back during the night in his nightmares and also during the day as flashbacks—uncontrollable, like a film he was forced to watch over and over. The highly traumatic experiences he described were the result of hallucinations and delirium during his life-threatening illness, but it also dawned on us that this young man was a veteran, a survivor of an imaginary war he had fought over weeks and months. The symptoms he described were clearly those of posttraumatic stress disorder (PTSD), a common anxiety disorder in veterans who had survived real wars. We discussed the case with one of our psychiatrists, who quickly confirmed the diagnosis of PTSD. We did not know if our patient represented a rare and exceptional complication of a prolonged and particularly difficult course of ARDS therapy or if PTSD was a more common, negative, emotional outcome of ICU therapy per se. As a consequence, we performed a number of retrospective and prospective studies in our patients after ARDS or ICU therapy for other reasons, in particular cardiac surgery. The results were sobering: Between 24% and 28% of long-term survivors of ARDS suffered from PTSD even many years after discharge from the ICU1Schelling G Stoll C Haller M et al.Health-related quality of life and post-traumatic stress disorder in survivors of the acute respiratory distress syndrome (ARDS).Crit Care Med. 1998; 26: 651-659Crossref PubMed Scopus (500) Google Scholar, 2Kapfhammer HP Rothenhäusler HB Krauseneck T Stoll C Schelling G Posttraumatic stress disorder and health-related quality of life in long-term survivors of acute respiratory distress syndrome.Am J Psychiatry. 2004; 161: 45-52Crossref PubMed Scopus (256) Google Scholar; the incidence of PTSD symptoms after ICU therapy for cardiac surgery was lower but still in the range of 18%.3Schelling G Richter M Roozendaal B et al.Exposure to high stress in the intensive care unit may have negative effects on health-related quality-of-life outcomes after cardiac surgery.Crit Care Med. 2003; 31: 1971-1980Crossref PubMed Scopus (174) Google Scholar These results have since been confirmed by a number of other researchers,4Davydow DS Desai SV Needham DM Bienvenu OJ Psychiatric morbidity in survivors of the acute respiratory distress syndrome: a systematic review.Psychosom Med. 2008; 70: 512-519Crossref PubMed Scopus (252) Google Scholar, 5Griffiths J Fortune G Barber V Young JD The prevalence of post traumatic stress disorder in survivors of ICU treatment: a systematic review.Intensive Care Med. 2007; 33: 1506-1518Crossref PubMed Scopus (169) Google Scholar and PTSD has become a concern for individuals caring for the critically ill. Despite these convincing epidemiologic data, the pathophysiology of PTSD development and specific risk factors for this disorder after ICU therapy are still poorly defined. Traumatic memories from adverse experiences in the ICU are an important risk factor for the development of PTSD after critical illness. Animal experiments have clearly shown that the glucocorticoid and the endocannabinoid systems play essential roles during encoding and consolidation of traumatic experiences into memory,6de Quervain DJ Aerni A Schelling G Roozendaal B Glucocorticoids and the regulation of memory in health and disease.Front Neuroendocrinol. 2009; 30: 358-370Crossref PubMed Scopus (405) Google Scholar, 7Campolongo P Roozendaal B Trezza V et al.Endocannabinoids in the rat basolateral amygdala enhance memory consolidation and enable glucocorticoid modulation of memory.Proc Natl Acad Sci USA. 2009; 106: 4888-4893Crossref PubMed Scopus (249) Google Scholar and single nucleotide polymorphisms influencing cortisol sensitivity of the glucocorticoid receptor gene in humans have been associated with an increased PTSD risk after malignant stress exposure,8van Zuiden M Geuze E Willemen HL et al.Glucocorticoid receptor pathway components predict posttraumatic stress disorder symptom development: a prospective study.Biol Psychiatry. 2012; 71: 309-316Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar including ICU therapy.9Hauer D Weis F Papassotiropoulos A et al.Relationship of a common polymorphism of the glucocorticoid receptor gene to traumatic memories and posttraumatic stress disorder in patients after intensive care therapy.Crit Care Med. 2011; 39: 643-650Crossref PubMed Scopus (87) Google Scholar Whereas an increased understanding of neurobiologic and genetic mechanisms leading to traumatic-memory formation and PTSD after exposure to extreme stress may one day allow the early identification of patients in the ICU who are at risk for PTSD, or the development of novel prophylactic measures,10Schelling G Kilger E Roozendaal B et al.Stress doses of hydrocortisone, traumatic memories, and symptoms of posttraumatic stress disorder in patients after cardiac surgery: a randomized study.Biol Psychiatry. 2004; 55: 627-633Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar, 11Zohar J Yahalom H Kozlovsky N et al.High dose hydrocortisone immediately after trauma may alter the trajectory of PTSD: interplay between clinical and animal studies.Eur Neuropsychopharmacol. 2011; 21: 796-809Abstract Full Text Full Text PDF PubMed Scopus (229) Google Scholar the question of a timely and reliable diagnosis of PTSD remains. The gold standard for PTSD diagnosis is the Clinician-Administered PTSD Scale (CAPS). The CAPS requires approximately 45 min to complete and an experienced clinician is needed to administer this instrument, which makes it impracticable for the routine screening of patients in the ICU or for use in a busy outpatient clinic. At this point, the work of the authors of a research paper appearing in this issue of CHEST (see page 24) comes in. Bienvenu et al12Bienvenu OJ Williams JB Yang A Hopkins RO Needham DM Posttraumatic stress disorder in survivors of acute lung injury: evaluating the Impact of Event Scale-Revised.Chest. 2013; 144: 24-31Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar validated a commonly used questionnaire for quantification of posttraumatic stress symptoms, the Impact of Event Scale-Revised (IES-R), against the CAPS gold standard in long-term survivors of acute lung injury (ALI). Their results are impressive: Sensitivities and specificities of the IES-R in their ALI population ranged between 80% to 100% and 85% to 91%, respectively. The original IES was not developed as a diagnostic tool covering only symptoms of intrusion and avoidance in the aftermath of single traumatic events. By adding items of autonomic hyperarousal, the IES-R has gained a sufficiently well-balanced factorial structure that comes close to the diagnostic criteria of PTSD according to the Diagnostic and Statistical Manual of Mental Disorders IV. And indeed, the validation study performed by Bienvenu et al12Bienvenu OJ Williams JB Yang A Hopkins RO Needham DM Posttraumatic stress disorder in survivors of acute lung injury: evaluating the Impact of Event Scale-Revised.Chest. 2013; 144: 24-31Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar suggests that this instrument can rapidly differentiate between patients with and without full or partial PTSD after ICU treatment because of ALI. Compared with the psychometric properties of the IES-R, the sensitivity of a previously validated questionnaire (the modified Posttraumatic Symptom Scale-10) against a structured interview by psychiatrists of long-term survivors of ARDS was lower (77%) and the specificity somewhat higher (97.5%).13Stoll C Kapfhammer HP Rothenhäusler HB et al.Sensitivity and specificity of a screening test to document traumatic experiences and to diagnose post-traumatic stress disorder in ARDS patients after intensive care treatment.Intensive Care Med. 1999; 25: 697-704Crossref PubMed Scopus (215) Google Scholar The original Posttraumatic Symptom Scale-10, however, was based on PTSD criteria of the Diagnostic and Statistical Manual of Mental Disorders III14Weisaeth L Torture of a Norwegian ship's crew. The torture, stress reactions and psychiatric after-effects.Acta Psychiatr Scand Suppl. 1989; 355: 63-72Crossref PubMed Scopus (98) Google Scholar; therefore, the addition and validation of the IES-R to the available screening PTSD instruments for patients after ICU therapy are both timely and appropriate. PTSD appears to be a common and often overlooked, negative, emotional outcome of severe illness and ICU therapy, and is associated with significant impairments in health-related quality of life,15Haagsma JA Polinder S Olff M Toet H Bonsel GJ van Beeck EF Posttraumatic stress symptoms and health-related quality of life: a two year follow up study of injury treated at the emergency department.BMC Psychiatry. 2012; 12: 1Crossref PubMed Scopus (58) Google Scholar an increased risk for alcohol and substance abuse,16Jacobsen LK Southwick SM Kosten TR Substance use disorders in patients with posttraumatic stress disorder: a review of the literature.Am J Psychiatry. 2001; 158: 1184-1190Crossref PubMed Scopus (818) Google Scholar and even cardiovascular disorders, resulting in premature morbidity and even death.17Boscarino JA A prospective study of PTSD and early-age heart disease mortality among Vietnam veterans: implications for surveillance and prevention.Psychosom Med. 2008; 70: 668-676Crossref PubMed Scopus (354) Google Scholar Effective treatments for PTSD exist and prophylactic strategies for PTSD prevention in critically ill patients need to be developed. Clearly, the responsibility of intensivists for veterans of the ongoing fight for survival in our ICUs does not end when the patients have survived, are discharged, and the ICU doors are closed behind them.