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Post-intensive care syndrome

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Post-intensive care syndrome (PICS) describes a collection of health disorders that are common among patients who survive critical illness and intensive care.[1] The range of symptoms that PICS describes falls under three broad categories: physical dysfunction, cognitive dysfunction, and mental health problems. A patient with PICS may suffer from symptoms from all three categories or just one.

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.[2] 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.[3] 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 is relatively new[when?] and arose, 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.[4] 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.

Conditions

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)

ICU-AW, sometimes called critical illness polyneuropathy, is thought to be an effect of long-term immobility and deep sedation that many critically ill patients experience while in the ICU.[5] In addition, severe infections and inflammation are significant risk factors for developing ICU-AW.[6] ICU-AW often presents as difficulty performing everyday activities (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.[7]

Cognitive dysfunction or impairment

Cognitive impairments include deficits in memory, attention, and problem solving. These impairments affect up to 80% of patients who survive a critical illness.[8] 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.

Mental health problems

Depression and anxiety are the two most common mental health problems seen in patients suffering from PICS.[9] The range of possible mental health problems, however, is far wider than just depression and anxiety. 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 false memories that some patients acquire during their stay in the ICU.[10]

Like ICU-AW, long-term immobility and deep sedation have been play an important part in the development of mental health problems seen in PICS.[11] [12] Sleep pattern disturbance, a common problem in the ICU, is also a likely culprit. Young age and female gender are also risk factors for PICS-related mental health problems.

The natural history for mental health problems is not well known, likely due to lack of recognition of these mental health symptoms as related to a remote ICU admission. With proper psychological and psychiatric help, mental health problems 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 mental health problems, 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 patients develop.[13] Healthcare providers, especially social workers who specialize in ICU care, can be especially helpful for advocating these practices and facilitating them for patients and families.

PICS-Family (PICS-F)

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).[14][15] Up to 30% of family and caregivers experience stress, anxiety, and symptoms of depression that fall under the category of PICS-F.[16]

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.[17] 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 bedside critical care nurses, can be especially helpful to identify those families who are at risk and to provide advice and resources whenever possible.

Treatment

Prevention

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.[18] 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.[19] 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, physical and occupational therapists, 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.

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, 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.

References

  1. ^ Medicine SoCC. Post-Intensive Care Syndrome. Patients and Families 2013; http://www.myicucare.org/Adult-Support/Pages/Post-intensive-Care-Syndrome.aspx. Accessed July 30, 2014.
  2. ^ 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.
  3. ^ Kress JP. Sedation and mobility: changing the paradigm. Critical care clinics. Jan 2013;29(1):67-75.
  4. ^ Medicine SoCC. Post-Intensive Care Syndrome. Patients and Families 2013; http://www.myicucare.org/Adult-Support/Pages/Post-intensive-Care-Syndrome.aspx. Accessed July 30, 2014.
  5. ^ Kress JP. Sedation and mobility: changing the paradigm. Critical care clinics. Jan 2013;29(1):67-75.
  6. ^ Prevention CfDCa. Critical Illness Polyneuropathy Critical Illness Myopathy. Centers for Disease Control and Prevention.
  7. ^ 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.
  8. ^ Group IDaCIS. ICU Delirium and Cognitive Impairment Study Group. ICU Delirium and Cognitive Impairment Study Group http://www.icudelirium.org/.
  9. ^ 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.
  10. ^ 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.
  11. ^ Kress JP. Sedation and mobility: changing the paradigm. Critical care clinics. Jan 2013;29(1):67-75.
  12. ^ 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
  13. ^ Mehlhorn J, Freytag A, Schmidt K, et al. Rehabilitation interventions for postintensive care syndrome: a systematic review. Critical care medicine. May 2014;42(5):1263-1271.
  14. ^ Davidson JE, Jones C, Bienvenu OJ. Family response to critical illness: postintensive care syndrome-family. Critical care medicine. Feb 2012;40(2):618-624.
  15. ^ 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.
  16. ^ Busko M. Relatives of ICU Patients May Experience Enduring Stress, Grief. http://www.medscape.org/viewarticle/581055.
  17. ^ 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.
  18. ^ Kress JP. Sedation and mobility: changing the paradigm. Critical care clinics. Jan 2013;29(1):67-75.
  19. ^ 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.
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