Abstract
Nowadays, more trauma patients develop chronic critical illness (CCI), a state characterized by prolonged intensive care. Some of these CCI patients have disproportional difficulties to recover and suffer from recurrent infections, a syndrome described as the persistent inflammation, immunosuppression and catabolism syndrome (PICS). A total of 78 trauma patients with an ICU stay of ≥14 days (CCI patients) between 2007 and 2017 were retrospectively included. Within this group, PICS patients were identified through two ways: (1) their clinical course (≥3 infectious complications) and (2) by laboratory markers suggested in the literature (C-reactive protein (CRP) and lymphocytes), both in combination with evidence of increased catabolism. The incidence of PICS was 4.7 per 1000 multitrauma patients. The sensitivity and specificity of the laboratory markers was 44% and 73%, respectively. PICS patients had a longer hospital stay (median 83 vs. 40, p < 0.001) and required significantly more surgical interventions (median 13 vs. 3, p = 0.003) than other CCI patients. Thirteen PICS patients developed sepsis (72%) and 12 (67%) were readmitted at least once due to an infection. In conclusion, patients who develop PICS experience recurrent infectious complications that lead to prolonged hospitalization, many surgical procedures and frequent readmissions. Therefore, PICS forms a substantial burden on the patient and the hospital, despite its low incidence.
Highlights
There has been much improvement in the clinical care for trauma patients, which has led to a decrease in mortality by exsanguination and life-threatening inflammatory complications, such as Acute Respiratory Distress Syndrome (ARDS), sepsis and multiple organ dysfunction syndrome (MODS) [1,2]
This syndrome has been described as the ‘persistent inflammation, immunosuppression and catabolism syndrome’ (PICS) [5,7,14], not to be confused with the post-intensive care syndrome [15]
As an intensive care stay of >2 weeks is the common denominator in most definitions of critical illness (CCI) and PICS, all patients ≥16 years of age with an intensive care unit (ICU) stay of 14 or more consecutive days during hospitalization were selected from the trauma registry database of the UMC Utrecht
Summary
There has been much improvement in the clinical care for trauma patients, which has led to a decrease in mortality by exsanguination and life-threatening inflammatory complications, such as Acute Respiratory Distress Syndrome (ARDS), sepsis and multiple organ dysfunction syndrome (MODS) [1,2]. No consensus exists on the definition of CCI [10,11], >14 days ICU stay is often used in recent literature [8,9,12] Some of these CCI patients suffer from poor wound healing, recurrent infections and a disproportionately slow recovery [7,8,13]. This syndrome has been described as the ‘persistent inflammation, immunosuppression and catabolism syndrome’ (PICS) [5,7,14], not to be confused with the post-intensive care syndrome [15]. Markers suggested in the literature include decreased lymphocyte counts, increased elevated C-reactive protein (CRP) levels and substantial weight loss or persistent decreased albumin levels [5,7]
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