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but often recovered not well enough to be discharged from the hospital and sent back home&#46;</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">This entity is defined by the Persistent Inflammation&#44; Immunosuppression&#44; and Catabolism Syndrome&#8221; &#40;PICS&#41;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and is characterized by a depressed adaptative immunity&#44; low&#8212;but persistent&#8212;level of inflammation&#44; diffuse apoptosis&#44; loss of lean mass&#44; and poor scarring-pressure ulcers&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The overall in-hospital mortality rate of these patients is 31&#37;&#46; This mortality rate is 16&#37;&#44; and 30&#37; 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associated with the cyclooxygenase 2 &#40;COX2&#41; promoter&#8212;of a heterogeneous population of immature myeloid cells &#40;IMC&#41; with immunosuppressant properties &#40;IP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the complex scheme of therapeutic approach both of immunosuppression and catabolism&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">From the clinical standpoint&#44; these patients are often ventilator-dependent&#44; and show cerebral dysfunction &#40;delirium&#41;&#44; neuromuscular weakness&#44; endocrinopathy &#40;loss of pulsatile secretion of the anterior pituitary&#44; hypogonadism&#41;&#44; malnutrition&#44; anasarca&#44; decubitus ulcers&#44; and discomfort &#40;pain&#44; thirst&#44; dyspnea&#44; anxiety&#44; and poor verbal communication due to tracheostomy&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Chronic critical illness is a devastating condition whose mortality rate exceeds that of malignant diseases&#46; In the United States alone&#44; the healthcare costs derived from the management of CIP are over US&#36;200 billion &#40;nearly &#1108;18 000 million&#41; and counting&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">We should bear in mind that&#44; on many occasions&#44; to safeguard patients and prevent the collapse of the healthcare personnel at the different hospital floors&#44; ICU discharges are often delayed&#46; This translates into longer ICU stays for clinically stable patients from LOC I&#44; and LOC II groups &#40;Levels of Critical Care&#46; ESCIM-Level of Care&#46; 2011&#41;&#46; Also&#44; they need constant care from the nursing team &#40;routine postural changes&#44; complex healing procedures&#44; repeated lab tests&#44; strict control of hydric balance&#44; aspiration of secretions&#44; etc&#46;&#41; that often exceed the capabilities of a conventional hospital ward&#46; Although these patients are often physiologically stable&#44; they are still exposed to complications associated with their primary diagnosis&#44; as well as to subsequent organ failures due to the interrelations among sepsis&#44; immune function&#44; and nutritional status&#46; This means that they need to be transferred to a different more friendly environment with a more suitable doctor&#47;nurse ratio &#40;lower actually&#41; where all nutritional&#44; rehabilitation&#44; and psychological needs are duly met&#59; we should mention that these units&#8212;necessarily cross-sectional&#8212;should be led by specialists in intensive medicine&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">All these aspects have sparked interest in specific units for less severe critically ill patients as a bridging therapy between the level of care provided at the ICU setting and at a conventional hospital floor&#44; which&#44; in turn&#44; is an opportunity to create more modern&#44; efficient&#44; and human structures&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> They should be transferred to chronic units in centers specialized in the management of these patients &#40;long-term acute care&#41; including the possibility of continuous monitorization&#58; ECG&#44; SpO<span class="elsevierStyleInf">2</span>&#44; and non-invasive arterial blood pressure monitoring&#46; Nurse control through telemetry and alarms&#44; mechanical ventilators&#44; BiPAP ventilation&#44; and different ventilation accessories and consumables facilitate the weaning process from the ventilator&#46; Rehabilitation equipment for chronic patients&#44; electrostimulation&#44; bicycles&#44; spirometers&#44; physical therapists&#8212;including respiratory physical therapists&#8212;rehabilitators&#44; psychologists&#44; and nutritionists&#44; added to a friendly setting for the proper physical and mental rehabilitation increase the patient&#8217;s autonomy&#44; humanization&#44; palliative care&#44; and the social&#44; and familial perspective&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span>"
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          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">BMI&#44; body mass index&#59; CHI&#44; creatinine&#47;height index&#59; CRP&#44; C-reactive protein&#59; ICU&#44; intensive care unit&#59; RbP&#44; retinol binding protein&#46;</p>"
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                  \t\t\t\t">Stay at the ICU setting &#62;14 days&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Weight loss &#62; 10&#37; during hospitalization or BMI &#60;18&nbsp;\t\t\t\t\t\t\n
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                      "Revista" => array:6 [
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                          "etal" => true
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Scientific Letter
Chronic critical illness, how to manage it?
Enfermedad crítica crónica ¿cómo abordarla?
A. García-de-Lorenzoa,b,
Corresponding author
agdl@telefonica.net

Corresponding author.
, J.M. Añóna,c, M.J. Asensioa, P. Burgueñod
a Servicio de Medicina Intensiva, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
b Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
c CIBER de Enfermedades Respiratorias, ISCIII, Madrid, Spain
d Servicio de Medicina Intensiva, Hospital 12 de Octubre, Madrid, Spain
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and 8&#37;&#44; 19&#37; in trauma patients&#44; and 40&#37; in septic patients&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">These patients are characterized by&#58;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0015" class="elsevierStylePara elsevierViewall">Stays at the intensive care unit &#40;ICU&#41; &#62;15 days&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0020" class="elsevierStylePara elsevierViewall">Dependency of mechanical ventilation &#40;&#62;4 weeks&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Advanced age&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Evidence of persistent organ dysfunction&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Survival to early aggression&#44; but often recovered not well enough to be discharged from the hospital and sent back home&#46;</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">This entity is defined by the Persistent Inflammation&#44; Immunosuppression&#44; and Catabolism Syndrome&#8221; &#40;PICS&#41;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and is characterized by a depressed adaptative immunity&#44; low&#8212;but persistent&#8212;level of inflammation&#44; diffuse apoptosis&#44; loss of lean mass&#44; and poor scarring-pressure ulcers&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The overall in-hospital mortality rate of these patients is 31&#37;&#46; This mortality rate is 16&#37;&#44; and 30&#37; in trauma and septic patients&#44; respectively&#44; at the 6-month follow-up&#46; However&#44; this rate can go up to 75&#37; at the 3-year follow-up&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In the management of the PICS complete recovery is almost impossible because from the standpoint of catabolism&#44; the syndrome drains all the energy from the body ultimate reserves&#46; Also&#44; because the immune system panics in response to the aggression and to the different therapies used&#58; the bone marrow releases a large number of immature cells that have mixed effects on the patient causing greater swelling and leaving the organism unprotected with the same efficacy compared to mature cells&#46; From the pathophysiological standpoint&#44; we should consider that emergency myelopoiesis emerges in response to an acute aggression at the expense of less lymphopoiesis and erythropoiesis&#44; which enhances anemia&#44; and lymphopenia&#46; Also&#44; it conditions the expansion&#8212;via signal transducer and activation of transcription 3 &#40;STAT3&#41; associated with the cyclooxygenase 2 &#40;COX2&#41; promoter&#8212;of a heterogeneous population of immature myeloid cells &#40;IMC&#41; with immunosuppressant properties &#40;IP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the complex scheme of therapeutic approach both of immunosuppression and catabolism&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">From the clinical standpoint&#44; these patients are often ventilator-dependent&#44; and show cerebral dysfunction &#40;delirium&#41;&#44; neuromuscular weakness&#44; endocrinopathy &#40;loss of pulsatile secretion of the anterior pituitary&#44; hypogonadism&#41;&#44; malnutrition&#44; anasarca&#44; decubitus ulcers&#44; and discomfort &#40;pain&#44; thirst&#44; dyspnea&#44; anxiety&#44; and poor verbal communication due to tracheostomy&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Chronic critical illness is a devastating condition whose mortality rate exceeds that of malignant diseases&#46; In the United States alone&#44; the healthcare costs derived from the management of CIP are over US&#36;200 billion &#40;nearly &#1108;18 000 million&#41; and counting&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">We should bear in mind that&#44; on many occasions&#44; to safeguard patients and prevent the collapse of the healthcare personnel at the different hospital floors&#44; ICU discharges are often delayed&#46; This translates into longer ICU stays for clinically stable patients from LOC I&#44; and LOC II groups &#40;Levels of Critical Care&#46; ESCIM-Level of Care&#46; 2011&#41;&#46; Also&#44; they need constant care from the nursing team &#40;routine postural changes&#44; complex healing procedures&#44; repeated lab tests&#44; strict control of hydric balance&#44; aspiration of secretions&#44; etc&#46;&#41; that often exceed the capabilities of a conventional hospital ward&#46; Although these patients are often physiologically stable&#44; they are still exposed to complications associated with their primary diagnosis&#44; as well as to subsequent organ failures due to the interrelations among sepsis&#44; immune function&#44; and nutritional status&#46; This means that they need to be transferred to a different more friendly environment with a more suitable doctor&#47;nurse ratio &#40;lower actually&#41; where all nutritional&#44; rehabilitation&#44; and psychological needs are duly met&#59; we should mention that these units&#8212;necessarily cross-sectional&#8212;should be led by specialists in intensive medicine&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">All these aspects have sparked interest in specific units for less severe critically ill patients as a bridging therapy between the level of care provided at the ICU setting and at a conventional hospital floor&#44; which&#44; in turn&#44; is an opportunity to create more modern&#44; efficient&#44; and human structures&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> They should be transferred to chronic units in centers specialized in the management of these patients &#40;long-term acute care&#41; including the possibility of continuous monitorization&#58; ECG&#44; SpO<span class="elsevierStyleInf">2</span>&#44; and non-invasive arterial blood pressure monitoring&#46; Nurse control through telemetry and alarms&#44; mechanical ventilators&#44; BiPAP ventilation&#44; and different ventilation accessories and consumables facilitate the weaning process from the ventilator&#46; Rehabilitation equipment for chronic patients&#44; electrostimulation&#44; bicycles&#44; spirometers&#44; physical therapists&#8212;including respiratory physical therapists&#8212;rehabilitators&#44; psychologists&#44; and nutritionists&#44; added to a friendly setting for the proper physical and mental rehabilitation increase the patient&#8217;s autonomy&#44; humanization&#44; palliative care&#44; and the social&#44; and familial perspective&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span>"
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          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">BMI&#44; body mass index&#59; CHI&#44; creatinine&#47;height index&#59; CRP&#44; C-reactive protein&#59; ICU&#44; intensive care unit&#59; RbP&#44; retinol binding protein&#46;</p>"
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                  \t\t\t\t">Stay at the ICU setting &#62;14 days&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Inflammation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Immunosuppression&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Total lymphocyte count &#60;0&#46;80&#8201;&#215;&#8201;10<span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Catabolism&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Weight loss &#62; 10&#37; during hospitalization or BMI &#60;18&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Albumin levels &#60;3&#46;0&#8201;g&#47;L&nbsp;\t\t\t\t\t\t\n
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                          "etal" => false
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ISSN: 21735727
Original language: English
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