Trauma ICU Rounds

Episode 51 - Persistent Inflammation, Immunosuppression & Catabolism Syndrome (PICS) with Dr. Scott Brakenridge

Feb 11, 2022

Dr. Scott Brakenridge, an expert in acute care surgery and sepsis research at the University of Florida, sheds light on Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PICS). He discusses its implications for critically ill patients, emphasizing that survival from conditions like sepsis is just the beginning of recovery. Dr. Brakenridge explores risk factors, the role of biomarkers, and the importance of personalized medicine. The conversation reveals groundbreaking advancements in managing sepsis and highlights strategies to prevent muscle loss and promote early mobilization.

43:46

Episode guests

Scott Brakenridge

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Quick takeaways

Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PICS) significantly impacts critically ill patients, often leading to long-term health issues following ICU discharge.

Early mobilization and adherence to best practices, such as the ABCDEF bundle, are essential for improving outcomes and preventing complications in ICU patients.

Deep dives

Understanding Persistent Inflammation and Chronic Critical Illness

The concept of Persistent Inflammation, Immunosuppression, and Catabolism (PIC) is crucial in understanding the outcomes of patients post-shock. Acute care surgeons have significantly improved mortality rates in septic and hemorrhagic shock over the past few decades, but this has led to the recognition of a new patient phenotype known as chronic critical illness (CCI). CCI patients often remain in the ICU for prolonged periods, exhibiting persistent organ dysfunction without improvement. Approximately half of the patients with CCI, particularly those with sepsis, face high mortality rates within one year post-ICU discharge, highlighting the importance of identifying and addressing this syndrome.

Intro

5min

Understanding PICS in Critical Illness

4min

Understanding Chronic Critical Illness in the ICU

9min

Advancements in Personalized Medicine for Sepsis Management

5min

Managing Trauma and Hemorrhagic Shock

12min

Managing Muscle Mass Loss in TBI Patients

10min

"Getting patients resuscitated through sepsis, septic shock, and hemorrhagic shock is not the end...it's the beginning."

In this episode, Dr. Brakenridge from Harborview Medical Center joins us to discuss PICS and the impact of this syndrome on our critically ill and injured patients and their families. Also referred to as the Post-Intensive Care Syndrome, Dr. Brakenridge shares with us the evolution and results of translational research into this now well-recognized morbid condition which often occurs in the setting of chronic critical illness. From the importance of breaking the cycle of "sepsis recidivism" to the. application of the SCCM A to F bundle, this episode is a MUST listen for those of us taking care of patients in the ICU.

TIME STAMPS
00:12 Introduction
01:46 What is PICS? The role of chronic critical illness (CCI)
05:13 Phenotypes vs. endotypes
06:47 The role of biomarkers in PICS
08:50 When does acute critical illness turn into CCI?
10:14 Risk factors for PICS
15: 07 Prognostication and determining patient trajectory
18:32 The Glue Grant Experience: Genomics of Injury
22:48 Hemorrhagic shock resuscitation: Then and now
25:33 Sepsis recidivism & avoiding secondary insults
29:08 ICU delirium
31:55 The role of early mobilization
32:41 The impact of catabolism in sepsis
34:50 Is there a role for anabolic steroids to counteract PICS?
37:52 What's ahead in terms of PICS translational research?
39:44 Cytokine and immunomodulator therapies
41:49 Final thoughts

RECOMMENDED READINGS
Brakenridge SC, Wang Z, Cox M, Raymond S, Hawkins R, Darden D, Ghita G, Brumback B, Cuschieri J, Maier RV, Moore FA, Mohr AM, Efron PA, Moldawer LL. Distinct immunologic endotypes are associated with clinical trajectory after severe blunt trauma and hemorrhagic shock. J Trauma Acute Care Surg. 2021 Feb 1;90(2):257-267.

Efron PA, Mohr AM, Bihorac A, Horiguchi H, Hollen MK, Segal MS, Baker HV, Leeuwenburgh C, Moldawer LL, Moore FA, Brakenridge SC. Persistent inflammation, immunosuppression, and catabolism and the development of chronic critical illness after surgery. Surgery. 2018 Aug;164(2):178-184. doi: 10.1016/j.surg.2018.04.011. Epub 2018 May 26.

Sauaia A, Moore FA, Moore EE. Postinjury Inflammation and Organ Dysfunction. Crit Care Clin. 2017 Jan;33(1):167-191.

Stortz JA, Murphy TJ, Raymond SL, Mira JC, Ungaro R, Dirain ML, Nacionales DC, Loftus TJ, Wang Z, Ozrazgat-Baslanti T, Ghita GL, Brumback BA, Mohr AM, Bihorac A, Efron PA, Moldawer LL, Moore FA, Brakenridge SC. Evidence for Persistent Immune Suppression in Patients Who Develop Chronic Critical Illness After Sepsis. Shock. 2018 Mar;49(3):249-258.