Stress Disorders Following Prolonged Critical Illness in Survivors of Severe Sepsis

Gloria-Beatrice Wintermann, PhD; Frank Martin Brunkhorst, MD; Katja Petrowski, PhD; Bernhard Strauss, PhD; Frank Oehmichen, MD; Marcus Pohl, MD; Jenny Rosendahl, PhD

Disclosures

Crit Care Med. 2015;43(6):1213-1222. 

In This Article

Abstract and Introduction

Abstract

Objectives To examine the frequency of acute stress disorder and posttraumatic stress disorder in chronically critically ill patients with a specific focus on severe sepsis, to classify different courses of stress disorders from 4 weeks to 6 months after transfer from acute care hospital to postacute rehabilitation, and to identify patients at risk by examining the relationship between clinical, demographic, and psychological variables and stress disorder symptoms.

Design Prospective longitudinal cohort study, three assessment times within 4 weeks, 3 months, and 6 months after transfer to postacute rehabilitation.

Setting Patients were consecutively enrolled in a large rehabilitation hospital (Clinic Bavaria, Kreischa, Germany) admitted for ventilator weaning from acute care hospitals.

Patients We included 90 patients with admission diagnosis critical illness polyneuropathy or critical illness myopathy with or without severe sepsis, age between 18 and 70 years with a length of ICU stay greater than 5 days.

Interventions None.

Measurements and Main Results Acute stress disorder and posttraumatic stress disorder were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, criteria by a trained and experienced clinical psychologist using a semistructured clinical interview for Diagnostic and Statistical Manual of Mental Disorders. We further administered the Acute Stress Disorder Scale and the Posttraumatic Symptom Scale-10 to assess symptoms of acute stress disorder and posttraumatic stress disorder. Three percent of the patients had an acute stress disorder diagnosis 4 weeks after transfer to postacute rehabilitation. Posttraumatic stress disorder was found in 7% of the patients at 3-month follow-up and in 12% after 6 months, respectively. Eighteen percent of the patients showed a delayed onset of posttraumatic stress disorder. Sepsis turned out to be a significant predictor of posttraumatic stress disorder symptoms at 3-month follow-up.

Conclusions A regular screening of post-ICU patients after discharge from hospital should be an integral part of aftercare management. The underlying mechanisms of severe sepsis in the development of posttraumatic stress disorder need further examination.

Introduction

With the advance of critical care medicine, the chance of survival after critical illness has tremendously increased.[1] The higher survival rate, especially in the aging population, is accompanied by an increased prevalence of prolonged critical illness of up to 10%.[2] Chronically critically ill patients suffer from a syndrome consisting of prolonged mechanical ventilation, renal replacement therapy, prolonged neuromuscular weakness, protracted coma, oneiric delirium, malnutrition, anasarca, and psychophysiological distress.[2] Furthermore, they exhibit an increased hospital lethality of about 50% and a 1-year survival rate of 25%.[3] Patients surviving critical illness often experience psychological sequelae, such as acute stress disorder (ASD) or posttraumatic stress disorder (PTSD). ASD is defined as short-term consequence occurring within 4 weeks after the traumatic event with the four symptom clusters: dissociative symptoms, traumatic reexperiencing, increased arousal, and avoidance of trauma-related stimuli. When these symptoms, except for dissociation, last more than 4 weeks, PTSD might be diagnosed.[4]

Systematic reviews report a median point prevalence of 19% and a range between 0% and 64% for posttraumatic stress symptoms following intensive care.[5–7] Among the included studies, the highest prevalence rates for moderate to severe symptoms of PTSD have been reported for sepsis survivors.[8–11] Schelling et al[10,11] reported the highest rates for PTSD in patients surviving septic shock with 59–64%. A current study found rates of clinically relevant PTSD symptoms in 69% of the patients.[12] However, the latter studies[10–12] used long and heterogeneous follow-up periods (up to 10 yr) and included only small and selected samples. Yet only one study has been explicitly focusing on sepsis as a risk factor for the development of PTSD, revealing that the proportion of ICU days with sepsis was independently associated with PTSD diagnosis within 2 years following ICU discharge.[13]

There is evidence for different courses of stress disorder symptoms after ICU discharge, that is, ICU survivors could have persistent PTSD symptomatology, could recover, have delayed onset of symptoms, or be resilient showing no symptoms at all. It has been shown that a substantial proportion of ICU survivors (16%) may have delayed onset of posttraumatic stress symptoms of clinical significance.[14]

The present study aimed at determining the frequency of ASD and PTSD from 4 weeks to 6 months after transfer from acute care hospital to postacute rehabilitation following prolonged critical illness with a specific focus on sepsis using valid structured diagnostic interviews.

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