Post-intensive care syndrome
Post-intensive care syndrome (PICS) describes a collection of health disorders that are common among patients who survive critical illness and intensive care. Generally, PICS is considered distinct from the impairments experienced by those who survive critical illness and intensive care following traumatic brain injury and stroke. The range of symptoms that PICS describes falls under three broad categories: physical impairment, cognitive impairment, and psychiatric impairment. A person with PICS may have symptoms from all three categories or just one. A video overview is available.
Improvements in survival after a critical illness have led to research focused on long-term outcomes for these patients. This improved survival has also led to the discovery of significant functional disabilities that many survivors of critical illness suffer. Because the majority of literature in critical care medicine is focused on short-term outcomes (e.g. survival), current understanding of PICS is relatively limited. Recent[when?] research suggests that there is significant overlap among the three broad categories of symptoms. In addition, sedation and prolonged immobilization seem to be common themes among patients who suffer from PICS.
The term PICS arose around 2010, at least in part, to raise awareness of the important long-term dysfunctions resulting from treatment in the intensive care unit (ICU). Awareness of these long-term functional disabilities is growing, and research is ongoing to further clarify the spectrum of disabilities and to find more effective ways to prevent these long-term complications and to more effectively treat functional recovery. Increased awareness in the medical community has also highlighted the need for more hospital and community-based resources to more effectively identify and treat patients with suffering from PICS after surviving a critical illness.
The most recognized form of the syndrome is the physical dysfunction commonly known as ICU-acquired weakness. The other physical, cognitive, and mental health impairments are less well recognized and need further research to be better understood.
ICU-acquired weakness (ICU-AW), sometimes called critical illness polyneuropathy, is the most common form of physical impairment, and is estimated to occur in 25 percent or more of ICU survivors. It is thought to be an effect of long-term immobility and deep sedation that many critically ill patients experience while in the ICU. In addition, severe infections and inflammation are significant risk factors for developing ICU-AW. ICU-AW often presents as difficulty performing activities of daily living (e.g. moving around the living environment, using the bathroom, ability to make meals or do laundry). Inability to effectively perform these tasks can be particularly distressing to patients. The deficits associated with ICU-AW have a direct and negative effect on a person’s independence. The natural course of ICU-AW is variable, but some patients recover within a year.
Other physical impairments include joint contractures due to long periods of immobility while hospitalized. The elbow and ankle are the most commonly affected joints, followed by the hip and knee. Some physical weakness may result from malnutrition during critical illness. Though nutrition may be provided by tube-feeding or parenteral nutrition, the initiation of parenteral nutrition may be delayed, and interruptions in feeding often occur due to gastrointestinal intolerance or the performance of procedures that require an empty stomach. In people who experience acute respiratory distress syndrome and are treated with mechanical ventilation, lung function is often compromised for months to years. The most commonly impaired lung function is diffusing capacity for carbon monoxide, as well as reduced lung volumes and spirometry.
Cognitive impairments include deficits in memory, attention, mental processing speed, and problem solving. These impairments affect up to 80% of individuals who survive a critical illness. Impairments in memory and executive function have the most profound effect in terms of prohibiting people from engaging in the tasks and behaviors needed to function effectively in daily life and carry out complex cognition. The effect of cognitive dysfunction is significant – unemployment is not uncommon because of difficulties with tasks of executive function (e.g. completing regular tasks like balancing a checkbook, and remembering facts or events). Among individuals with PICS-associated cognitive impairments, most patients improve or completely resolve over the first year.
Major risk factors for cognitive impairment following ICU admission due to critical illness include delirium, prior cognitive deficit, sepsis, and acute respiratory distress syndrome (ARDS). It is currently believed that many factors can play a role in causing cognitive impairment following critical illness. Some possible mechanisms for include poor blood supply to the brain due to low blood pressure from sepsis, poor oxygen supply to the brain due to respiratory distress and impairment, inflammation of the brain, and disruption of the blood-brain barrier in the areas of the brain that are involved in executive function and memory
Depression and anxiety are the two most common mental health disorders seen in individuals with PICS. The range of possible mental health problems, however, is far wider. Dementia, post-traumatic stress disorder (PTSD), and persistent delusional behavior are also manifestations of the syndrome. Although not completely understood, the anxiety and delusions seen in patients with PICS are likely linked to delusional memories that some individuals acquire during their stay in the ICU, rather than recall of factual memories. It is thought that medically-induced sedation may contribute to the formation delusional memories by raising the risk of delirium and hallucinations.
Risk factors are similar to those for cognitive impairment following critical illness, and include severe sepsis, acute respiratory distress syndrome, respiratory failure, trauma, hypoglycemia, and hypoxemia. Like ICU-acquired weakness, long-term immobility and deep sedation have been known to play an important part in the development of mental health problems seen in PICS. Sleep pattern disturbance, a common problem in the ICU, is also a likely culprit. Age under 50 years, female gender, lower education level, pre-existing disability, alcohol abuse, pre-existing anxiety, depression, and PTSD are also risk factors for PICS-related mental health disorders.
The natural history for mental health disorders following critical illness is not well known, likely due to lack of recognition that these psychiatric symptoms may be related to a remote ICU admission. With proper psychological and psychiatric help, mental illness related to PICS can be successfully managed, but research favors preventative strategies as the most effective management. While there are ongoing studies focused on determining the best way to treat and prevent psychiatric problems following critical illness, daily diaries, so-called “ICU diaries” seem to be the most promising. These ICU diaries appear to be effective in treating the delusional, false memories that some of these individuals develop. Healthcare providers, especially clinical social workers who specialize in medical care, can be very helpful for advocating these practices and facilitating them for patients and families.
Episodes of critical illness also impact families and caregivers which in turn can affect those recovering from their critical illness. Increasing awareness of PICS has also brought to light a set of psychological symptoms that family members of critically ill patients often suffer. Recognition of these set of symptoms has given rise to the term PICS-Family (PICS-F). Up to 30% of family and caregivers experience stress, anxiety, and symptoms of depression that fall under the category of PICS-F.
The symptoms seen in PICS-F are largely the same set of mental health symptoms that patients with PICS suffer and may have some basis in the anxiety and false memories that these family members develop during the course of the critical illness. These symptoms can cause caregivers to stop maintaining their own health. Family members can also feel overwhelmed when they are asked to make unexpected life and death decisions about the care of their loved ones. After discharge from the ICU, persistence symptoms of depression, anxiety and PTSD is the rule rather than the exception for PICS-F. But like the mental health problems in PICS, PICS-F symptoms can be successfully managed with proper recognition and treatment. As in PICS, self-care is an important part component of preventing PICS-F. Patients' families often suffer from some of the similar stresses as the ICU patients themselves, including sleep deprivation and severe psychological stresses an unfamiliar and uncomfortable environment – Particular attention from healthcare workers, especially medically trained clinical social workers and critical care nurses, can be helpful to identify those families who are at risk and to provide advice and resources whenever possible.
Although there are promising methods for treating PICS, prevention should be the primary focus. When strategies at primary prevention have failed, recognizing the syndrome and its long-term effects have been a significant step in effectively treating PICS.
Limiting deep sedation and immobility and bed-rest have had the largest impact in preventing the long-term functional deficits seen in PICS. Attention to sleep hygiene while in the ICU also seems to be an important part of prevention. Early recognition and treatment of delirium appears to decrease the incidence of PICS. Early, aggressive physical and occupational therapy have had a positive effect. In addition, a focused effort by the ICU health care team should reinforce the importance to family and patients regarding maintaining self-care including hygiene, adequate sleep and nutrition during and after the course of ICU stay.
Other treatments, long-term follow-up measures and resources
Because PICS represents a range of disorders, no single treatment is likely to adequately address all the symptoms associated with the syndrome. Care can be sought from a variety of professionals, including primary care physicians, nurse practitioners, physical and occupational therapists, clinical social workers trained in medical social work, psychiatrists and psychologists. In addition, there is a growing trend of dedicated follow-up clinics for ICU patients that show some promise for recognizing and triaging patients. They often offer support groups for patients and families affected by PICS and PICS-F.
Patients and caregivers should look for signs and symptoms associated with PICS or PICS-F including muscle weakness, fatigue, trouble with daily activities, memory or thinking problems, anxiety and depression, or nightmares and unwanted memories after leaving the ICU. If these symptoms are recognized, consulting a primary care doctor or other caregiver can help. Many other specialists can be enlisted to help patients recover including occupational or physical therapists, medically trained clinical social workers, psychiatrists, psychiatrists or psychologists, and speech therapists. Patients and families who have questions or concerns regarding PICS or PICS-F should refer to their local hospital and ICU for available resources.
- Medicine SoCC. Post-Intensive Care Syndrome. Patients and Families 2013; "Archived copy". Archived from the original on 2015-06-13. Retrieved 2015-06-13. . Accessed July 30, 2014.
- Needham DM, Davidson J, Cohen H, Hopkins RO, Weinert C, Wunsch H, Zawistowski C, Bemis-Dougherty A, Berney SC, Bienvenu OJ, Brady SL, Brodsky MB, Denehy L, Elliott D, Flatley C, Harabin AL, Jones C, Louis D, Meltzer W, Muldoon SR, Palmer JB, Perme C, Robinson M, Schmidt DM, Scruth E, Spill GR, Storey CP, Render M, Votto J, Harvey MA (2012). "Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference". Crit. Care Med. 40 (2): 502–9. doi:10.1097/CCM.0b013e318232da75. PMID 21946660.
- SCCM. "THRIVE: Life After the Intensive Care Unit". Retrieved 2 June 2016.
- Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Critical care medicine. Feb 2012;40(2):502-509.
- Kress JP. Sedation and mobility: changing the paradigm. Critical care clinics. Jan 2013;29(1):67-75.
- Hermans G, Van Mechelen H, Clerckx B, Vanhullebusch T, Mesotten D, Wilmer A, Casaer MP, Meersseman P, Debaveye Y, Van Cromphaut S, Wouters PJ, Gosselink R, Van den Berghe G (2014). "Acute outcomes and 1-year mortality of intensive care unit-acquired weakness. A cohort study and propensity-matched analysis". Am. J. Respir. Crit. Care Med. 190 (4): 410–20. doi:10.1164/rccm.201312-2257OC. PMID 24825371.
- Pandharipande PP, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT, Brummel NE, Hughes CG, Vasilevskis EE, Shintani AK, Moons KG, Geevarghese SK, Canonico A, Hopkins RO, Bernard GR, Dittus RS, Ely EW (2013). "Long-term cognitive impairment after critical illness". N. Engl. J. Med. 369 (14): 1306–16. doi:10.1056/NEJMoa1301372. PMC 3922401. PMID 24088092.
- Prevention CfDCa. Critical Illness Polyneuropathy Critical Illness Myopathy. Centers for Disease Control and Prevention.
- Nordon-Craft A, Moss M, Quan D, Schenkman M. Intensive care unit-acquired weakness: implications for physical therapist management. Physical therapy. Dec 2012;92(12):1494-1506.
- Clavet H, Hébert PC, Fergusson D, Doucette S, Trudel G (2008). "Joint contracture following prolonged stay in the intensive care unit". CMAJ. 178 (6): 691–7. doi:10.1503/cmaj.071056. PMC 2263098. PMID 18332384.
- Heyland DK, Schroter-Noppe D, Drover JW, Jain M, Keefe L, Dhaliwal R, Day A (2003). "Nutrition support in the critical care setting: current practice in canadian ICUs--opportunities for improvement?". JPEN J Parenter Enteral Nutr. 27 (1): 74–83. doi:10.1177/014860710302700174. PMID 12549603.
- Orme J, Romney JS, Hopkins RO, Pope D, Chan KJ, Thomsen G, Crapo RO, Weaver LK (2003). "Pulmonary function and health-related quality of life in survivors of acute respiratory distress syndrome". Am. J. Respir. Crit. Care Med. 167 (5): 690–4. doi:10.1164/rccm.200206-542OC. PMID 12493646.
- Group IDaCIS. ICU Delirium and Cognitive Impairment Study Group. ICU Delirium and Cognitive Impairment Study Group http://www.icudelirium.org/.
- Sukantarat KT, Burgess PW, Williamson RC, Brett SJ (2005). "Prolonged cognitive dysfunction in survivors of critical illness". Anaesthesia. 60 (9): 847–53. doi:10.1111/j.1365-2044.2005.04148.x. PMID 16115244.
- Mikkelsen ME, Christie JD, Lanken PN, Biester RC, Thompson BT, Bellamy SL, Localio AR, Demissie E, Hopkins RO, Angus DC (2012). "The adult respiratory distress syndrome cognitive outcomes study: long-term neuropsychological function in survivors of acute lung injury". Am. J. Respir. Crit. Care Med. 185 (12): 1307–15. doi:10.1164/rccm.201111-2025OC. PMC 3381234. PMID 22492988.
- Annane D, Sharshar T (2015). "Cognitive decline after sepsis". Lancet Respir Med. 3 (1): 61–9. doi:10.1016/S2213-2600(14)70246-2. PMID 25434614.
- Morandi A, Rogers BP, Gunther ML, Merkle K, Pandharipande P, Girard TD, Jackson JC, Thompson J, Shintani AK, Geevarghese S, Miller RR, Canonico A, Cannistraci CJ, Gore JC, Ely EW, Hopkins RO (2012). "The relationship between delirium duration, white matter integrity, and cognitive impairment in intensive care unit survivors as determined by diffusion tensor imaging: the VISIONS prospective cohort magnetic resonance imaging study*". Crit. Care Med. 40 (7): 2182–9. doi:10.1097/CCM.0b013e318250acdc. PMC 3378755. PMID 22584766.
- Desai SV, Law TJ, Needham DM (2011). "Long-term complications of critical care". Crit. Care Med. 39 (2): 371–9. doi:10.1097/CCM.0b013e3181fd66e5. PMID 20959786.
- Burling S. A new frontier in ICU research: Postintensive care syndrome. Philly.com 2013; http://articles.philly.com/2013-03-27/news/38043544_1_icu-patients-delirium-critical-care. Accessed July 30, 2014.
- Hoffman J. Nightmares After the I.C.U. Well 2013; http://well.blogs.nytimes.com/2013/07/22/nightmares-after-the-i-c-u/. Accessed July 30, 2014.
- Jones C, Griffiths RD, Humphris G, Skirrow PM (2001). "Memory, delusions, and the development of acute posttraumatic stress disorder-related symptoms after intensive care". Crit. Care Med. 29 (3): 573–80. doi:10.1097/00003246-200103000-00019. PMID 11373423.
- Davydow DS, Hough CL, Langa KM, Iwashyna TJ (2013). "Symptoms of depression in survivors of severe sepsis: a prospective cohort study of older Americans". Am J Geriatr Psychiatry. 21 (9): 887–97. doi:10.1097/JGP.0b013e31825c0aed. PMC 3462893. PMID 23567391.
- Davydow DS, Desai SV, Needham DM, Bienvenu OJ (2008). "Psychiatric morbidity in survivors of the acute respiratory distress syndrome: a systematic review". Psychosom Med. 70 (4): 512–9. doi:10.1097/PSY.0b013e31816aa0dd. PMID 18434495.
- Jackson JC, Obremskey W, Bauer R, Greevy R, Cotton BA, Anderson V, Song Y, Ely EW (2007). "Long-term cognitive, emotional, and functional outcomes in trauma intensive care unit survivors without intracranial hemorrhage". J Trauma. 62 (1): 80–8. doi:10.1097/TA.0b013e31802ce9bd. PMID 17215737.
- Dowdy DW, Dinglas V, Mendez-Tellez PA, Bienvenu OJ, Sevransky J, Dennison CR, Shanholtz C, Needham DM (2008). "Intensive care unit hypoglycemia predicts depression during early recovery from acute lung injury". Crit. Care Med. 36 (10): 2726–33. doi:10.1097/CCM.0b013e31818781f5. PMC 2605796. PMID 18766087.
- Hoffman J. Nightmares After the I.C.U. Well 2013; http://well.blogs.nytimes.com/2013/07/22/nightmares-after-the-i-c-u/. Accessed July 30, 2014
- Hopkins RO, Key CW, Suchyta MR, Weaver LK, Orme JF (2010). "Risk factors for depression and anxiety in survivors of acute respiratory distress syndrome". Gen Hosp Psychiatry. 32 (2): 147–55. doi:10.1016/j.genhosppsych.2009.11.003. PMID 20302988.
- Mehlhorn J, Freytag A, Schmidt K, et al. Rehabilitation interventions for post-intensive care syndrome: a systematic review. Critical care medicine. May 2014;42(5):1263-1271.
- Davidson JE, Jones C, Bienvenu OJ. Family response to critical illness: postintensive care syndrome-family. Critical care medicine. Feb 2012;40(2):618-624.
- Schmidt M, Azoulay E. Having a loved one in the ICU: the forgotten family. Current Opinion in Critical Care. Oct 2012;18(5):540-547.
- Busko M. Relatives of ICU Patients May Experience Enduring Stress, Grief. http://www.medscape.org/viewarticle/581055.
- Wiedermann CJ, Lehner GF, Joannidis M. From persistence to palliation: limiting active treatment in the ICU. Current Opinion in Critical Care. Dec 2012;18(6):693-699.
- Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. May 30, 2009;373(9678):1874-1882.