Patients after discharge from the icu.pptx

Post-Intensive Care Syndrome
(PICS )
Dr: Ahmed Hamdy
Lecturer of Anesthesia and Intensive Care Unit-Benha
University

• The advancement in the critical care medicine
and consequently, the improvement in
survival after a critical illness have led the
clinicians to discover the significant functional
disabilities that many of these surviving
patients suffer. This has led to further research
which is focused on improving the long-term
outcomes for the critical illness survivors and
their functional recovery.

• Attendees of a 2010 meeting of the Society of
Critical Care Medicine coined the term Post
Intensive Care Syndrome (PICS)

Post-intensive care syndrome (PICS)
Definition:
Although there is no official definition for
post-intensive care syndrome (PICS), most
clinicians agree that PICS constitutes new or
worsening function in one or more of the
following domains after critical illness
(Pšenička et al., 2021):
• Cognitive function
• Psychiatric function
• Physical function(Ni et al., 2022)

• traumatic brain injury (TBI) or cerebrovascular accident
(CVA), have been excluded
• Consequent to this, the psychological health of family
members of the survivor may also be affected in an adverse
manner, termed as PICS-Family (PICS-F) who experience
subsequent adverse mental health outcomes, the most
common of which are sleep deprivation, anxiety,
depression, and complicated grief (Brown et al., 2019).
• the PICS-pediatric (PICS-p) is applicable to all family
members of the PICU patient
• there is no set duration of time after a critical illness where
PICS can or cannot occur
(Martillo et al., 2021).

• 1.5-Risk factors:
• Risk factors for the development of post-intensive care syndrome (PICS) vary depending on the component of
PICS that is studied. Risk factors can be broadly categorized into the following (Puthucheary et al., 2022):
• Pre-existing factors (eg, neuromuscular disorders, cognitive impairment, psychiatric illness, comorbid
conditions, functional decline, frailty)
• Intensive care unit (ICU)-specific factors (eg, mechanical ventilation, acute delirium, sepsis, acute respiratory
distress syndrome)
• Factors associated with socioeconomic disadvantage may also contribute to the development of PICS,
particularly in older adults (>65 years). (Ramalingam et al., 2020).There did not appear to be an increased risk
for depression or anxiety. Potentially related to socioeconomic disadvantage and/or pre-existing functional
decline, social isolation was associated with greater disability and increased one-year mortality after an ICU
hospitalization. Additional factors that may contribute to this disparity are unclear and need further study
(Landoni et al., 2020).
• Additional cited risk factors include acute brain dysfunction (eg, alcoholism, stroke), hypoxemia (eg, acute
respiratory distress syndrome, cardiac arrest), hypotension (eg, sepsis, trauma), glucose dysregulation,
respiratory failure (eg, prolonged mechanical ventilation, chronic obstructive pulmonary disease), congestive
heart failure, cardiac surgery, obstructive sleep apnea, acute in hospital stress/inflammation, blood
transfusions, sedative medications, delirium, and use of renal replacement therapy (Jaffri et al., 2020).
• Risk factors for psychiatric disease (eg, anxiety, depression, posttraumatic stress disorder [PTSD]) are similar to
those for cognitive impairment following critical illness. They include severe sepsis and ARDS as well as
respiratory failure, trauma, and hypoglycemia. Pre-existing anxiety, depression, and PTSD increase the risk of
ICU-related psychiatric symptoms, as well as female sex, tall stature in males, age <50 years, lower education
level, pre-existing disability/unemployment, premorbid alcohol abuse, ICU sedative and analgesia use,
recollection of frightening experiences in the ICU, and early symptoms of mental health impairments after
critical illness (Colbenson et al., 2019).
• Glucocorticoids are associated with a reduced risk for PTSD. Reduced levels of cortisol are thought to play a role
in the development of PTSD, and it has been hypothesized that the administration of glucocorticoids during a
critical illness may replenish cortisol levels thereby reducing the risk of developing PTSD

Etiology:
• physical impairments of (PICS) arise from ICU-
acquired muscle weakness (ICUAW),
• diffuse symmetrical decrease in skeletal muscle
strength for which other causes have been
excluded. The clinical manifestations of ICUAW
may include difficulty in ventilator weaning,
impairments in speaking or swallowing, and
generalized weakness of the limbs. ICUAW is
further subdivided into muscle deconditioning,
(CIP), and (CIM), the latter two of which may
coexist as (CINM)

Subclassification of the mechanisms of intensive care unit-acquired weakness (ICU-AW)
into two main groups. The first group is ICU-AW with electrophysiologic and
histopathologic findings (critical illness polyneuropathy [CIP] and critical illness
myopathy [CIM]); the other is ICU-AW with normal diagnostic studies. CIM, abnormal
reduction in the amplitude of compound muscle action potentials (CMAPs) and an
increase in their duration, normal sensory nerve action potentials (SNAPs), reduced
muscle excitability on direct stimulation, and myopathic motor unit potentials on
needle electromyography; CINM, critical illness neuromyopathy, coexistence of CIP and
CIM; CIP, reduction in the amplitude of CMAPs and SNAPs with normal or mildly
reduced nerve conduction velocity; Muscle deconditioning, normal nerve conduction
velocity and compound motor action potential, absence of spontaneous activity

• unloading respiratory musculature by mechanical ventilation,
prolonged bed rest, and other forms of immobilization also rapidly
weaken the limb and trunk muscles of ICU patients
• In addition to skeletal muscle atrophy from disuse, inflammatory
mediators, electrolyte imbalances, endocrine dysfunction, and poor
nutritional status also frequently contribute to the myopathy of
ICUAW by impairing protein synthesis and promoting
proteolysis.[3] Vitamin D deficiency, which is quite common in the
general population and exacerbated by sunlight deprivation in
hospitalized patients, is also probably an underappreciated and
reversible contributor to skeletal muscle weakness in the ICU
setting, particularly among those with darker skin tones.[6] Many of
these factors, as well as microvascular ischemia, also likely underlie
the neuropathic components of ICUAW

• Factors that may contribute to deteriorating muscle function in critically ill
patients, according to current theories, include the prolonged catabolic
state and bed rest induced by stress and critical illness, and the evolution
of ischemia in the microvascular level of the muscle and supplying nerves
that can damage cellular ion channels and mitochondria. Although muscle
weakness may resolve after several weeks to months, in numerous cases,
the impairment of motor function persists for months to years. The
presence of joint contractures and/or ectopic ossifications may actually
further worsen motor function and HRQOL (Marra et al., 2018).
• Critically ill COVID-19 survivors are likely at increased risk for chronic pain,
which can further affect rehabilitation and recovery. According to current
guidelines, COVID-19 patients with severe symptoms are treated with
steroids. Steroid use is known to cause significant side effects, namely
immune dysfunction, dysglycemia, frail skin, osteoporosis, sarcopenia, loss
of muscle mass, nervousness, and changes in mood (Hall et al., 2022).
(Figure 4)

Commonest symptoms that characterize the post-intensive care syndrome in non-
COVID-19 and COVID-19 patients

• The cognitive impairment of PICS may manifest as deficits in
memory, processing speed, or attention that persist up to years
following ICU discharge.[8] Risk factors for these deficits in ICU
survivors include prolonged or frequent periods of hyper- or
hypoglycemia and pre-existing cognitive deficits.[7] A large study
from 1999 of ARDS patients also found that more extended and
more profound periods of hypoxia during the ICU period correlated
with an increased risk for cognitive deficits one year later.[9] There
is also a secure link between ICU delirium and the subsequent
cognitive deficits of PICS. The 2013 BRAIN ICU study of over 800 ICU
patients revealed that a longer duration of delirium, but
interestingly not a coma, increased the risk of cognitive impairment
one year post-discharge.[10]

• 2Cognitive impairments in PICS
• Critically ill patients experience high levels of physical and psychological stress in
the ICU; these experiences result in cognitive impairments in patients with PICS.
New or worsening impairments in cognitive function persist months to years after
hospital discharge and are associated with poor daily functioning and reduced
quality of life. Cognitive impairments include impaired memory, executive
function, language, attention, and visual–spatial abilities (Martillo et al., 2021).
• Dementia is a relevant disease of cognitive dysfunction (figure 5)and a number of
studies have reported the association between dementia and ICU treatment.
Among 10,348 intensive care patients who survived hospital discharge, dementia
was newly diagnosed in 1,648 (15.0%) over 3 years of follow-up compared to
12.2% in the general population. Furthermore, pre-existing cognitive impairment
in ICU populations is widespread. A cross-sectional comparative study reported
that 37% of critically ill patients over 65 years of age in the ICU had pre-existing
cognitive impairment. Pre-existing cognitive impairment also affects cognitive
function in PICS

Three common cognitive impairments among older adults: delirium, dementia, and
depression

• The pathophysiology of cognitive impairment after ICU treatment remains
unknown and might be a manifestation of brain dysfunction. However, further
research is needed (Stam et al., 2020).
• The term “cognitive dysfunction” refers to persistent defects in brain function,
combined with behavioral and emotional changes, that result in the inability to
function normally in everyday life and subsequently low HRQOL. Patients with
cognitive dysfunction often present with problems in memory, attention, speed of
mental processing, speaking and executive ability, with the latter including
organization, design, and problem-solving (Landoni et al., 2020).
• ICU delirium, which is a multifactorial condition with complex
pathophysiology(figure 6), is the best-studied risk factor in surgical and general ICU
populations, and a relationship between the length of delirium and cognitive
decline has been described in ARDS. COVID-19 patients are at increased risk of
developing ICU delirium due to invasion of the central nervous system from the
virus, the inflammatory storm syndrome that is accompanied by encephalopathy,
and the severity of multiple organ failure also affecting the brain

ICU delirium has a complex and multifactorial pathophysiology at the cellular and
molecular level that affects the clinical level with significant overlap. This complexity
explains the observed difficulty in delirium treatment and highlights the importance of
prevention. GABA, Gamma-aminobutyric acid; ICU, Intensive care unit; NMDA, N-methyl-
D-aspartate

• impairments in mental health function, including depression, anxiety, and
post-traumatic stress disorder (PTSD). These psychiatric sequelae are
perhaps not surprising, given that the experience of being an ICU patient
is often isolating, frightening, and dehumanizing. Repetitive exposure to
physical pain and discomfort is also frequent, as is a general feeling of
disorientation and confusion that arises from prolonged sedation or
delirium. Risk factors for the development of mental health problems
following an ICU stay include a personal history of psychiatric illness,
female gender, and younger age. Exposure to sedative agents during the
ICU stay, and limited recall of the ICU experience also increases the risk of
subsequent mental health impairments. At the same time, the emergence
of intrusive traumatic memories and nightmares during hospitalization
may herald problems that persist post-discharge.[11] There is also
evidence to suggest that hypoglycemia and hypoxia not only increase the
risk of cognitive dysfunction in ICU survivors but may contribute to
depressive symptoms as well.

• Risk factors for family members to develop PICS-f include female gender, younger
age, lower educational level, and previous history of mental health disorders.
Spouses of ICU patients are particularly at risk as are the unmarried parents of
critically ill children. However, overall the family members of pediatric ICU patients
compared to adults are less likely to develop the syndrome.[14] There is conflicting
evidence regarding whether family involvement in medical decision-making is
protective or predictive of subsequent PICS-f, and cultural factors may explain
differences across studies. For example, a French study found that being a
decision-maker and particularly having to be involved in end-of-life decisions
increased the risk of PICS-f.[15] Conversely, a US study identified that family
members who adopted a passive role in decision-making were actually at
increased risk for adverse mental health sequelae.[16] These seemingly
contradictory findings may be explained by differences between the two countries
regarding the acceptability and pervasiveness of shared medical decision-making.
While shared decision-making is the norm in the US, the practice is not as well
established in France, and family members may be more likely to find involvement
in making decisions for a critically ill loved one to be psychologically burdensome
or even traumatic.[14]

• Patients admitted to the ICU with COVID-19 experience additional stress resulting from physical isolation and distancing
from relatives, friends, and healthcare professionals due to strict preventive measures and extensive use of personal
protective equipment (Flaws et al., 2021).
• Depression
• Depression symptoms are important for ICU survivors. Their recognition is paramount since their presence has been linked
to prolonged abstain from work, decreased HRQOL, and suicide risk. Potential pathogenetic mechanisms of depression and
anxiety in ICU survivors involve organ dysfunction, medications, pain, lack of sleep, increased cytokine levels, stress-related
activation of the hypothalamic-pituitary axis, hypoxemia, and brain injury-induced neurotransmitter dysfunction. Depression
occurs in 25–60% of survivors of critical illness (Stam et al., 2020).
• A significant association between post-ICU depressive symptoms measured at hospital discharge and female sex has been
described. It has also been documented that depressed mood in the month prior to ICU admission could predict depressive
symptoms up to 2- and 6-months post-ICU, as could poor pre-ICU physical functioning. There are several studies that have
examined the association between ICU treatment and depression. ICU length of stay and severity of illness at ICU admission,
as measured by the APACHE II score, were not significant predictors for depressive symptoms. Studies have also examined
the predictive ability of early post-ICU memories of in-ICU experiences in depressive symptoms. Stressful memories and
nightmares while in the ICU or a sense of fear 5 days post-discharge could predict depressive symptoms later in life
(Pšenička et al., 2021).
• Anxiety
• Anxiety is the least studied symptom in ICU survivors. It is related to other psychiatric symptoms, memories, and delusions,
while patients with anxiety also report excess unrest, sensitivity, and fatigue. In ICU survivors, the reported frequencies for
anxiety range from 16–62%, however different tools for assessing symptoms have been used at different time points post-
discharge. There was no difference in anxiety frequency between medical or surgical patients or patients with trauma.
Anxiety symptoms seem to persist from 3 to 14 months after ICU discharge. No correlation has been shown between anxiety
and age, sex, disease severity, or length of ICU stay (Brown et al., 2019).
• Post-Traumatic Stress Disorder (PTSD)
• PTSD’s main characteristic is the exposure of a subject to an event that is life-threatening or perceived as such. Following this
traumatic experience, patients present with intrusive thoughts, avoidant behavior, general irritability or paranoia, and other
hyperarousal symptoms, reduced cognition involving the inability to concentrate on one thing, and mood disturbance. The
association between PTSD and critical illness remains unclear, while prevalence estimates vary significantly from 4 to 62% of
ICU survivors

Epidemiology
• Physical impairment is present in 25-80% of adult ICU
survivors. It is even more prevalent among survivors of
sepsis[18], possibly due to the involvement of
inflammatory cytokines in the pathogenesis of
ICUAW.[19] Cognitive dysfunction occurs in up to 80%
of adult ICU survivors, and while this generally
improves over time, these changes may persist for
years, particularly following recovery from ARDS or
sepsis. Rates of Post Traumatic Stress Disorder (PTSD)
have been reported in up to 50% of adult ICU survivors,
and this particular malady also tends to persist for
years following hospital discharge.[18]

• A recent study by Marra and colleagues of 406 adult ICU patients from five US
medical centers evaluated the co-occurrence of PICS impairments 3- and 12-
months post-discharge. These investigators found 64% and 56% of survivors had
one or more PICS impairments after 3 and 12 months, respectively. The co-
occurrence of impairments across two or more domains was also found to be
shared with cognitive and psychological problems being the most persistent over
time. Additionally, increased education level and lower frailty scores were
positively correlated with being PICS free at both points of follow-up.[20] The
BRAIN-ICU longitudinal cohort study of critical care survivors in the Nashville, TN
area found a 29% prevalence of depression at 12 months post-discharge, but a
relatively low rate of PTSD at 7%. In this population, over a quarter still required
aid in the necessary activities of daily living (ADL) in one year.[21] Up to 75% of
family members of ICU patients develop symptoms consistent with PICS-f, with
approximately a third requiring psychiatric medication for management.[18] The
most common mental health problem in family members is anxiety, with
depression and PTSD being somewhat less frequent.[14] Importantly, PICS-f may
exacerbate the existing physical health problems in family members as well as
contribute to financial and substance abuse issues.[18]

• In advanced countries, PICU mortality rates
have fallen from approximately 5% to 2.5%
since the year 2000.[22][23] Because pediatric
ICU patients are more likely to survive than
their adult counterparts, recognizing the
scope of persistent morbidity in this
population is of particular need for further
study.

Pathophysiology
• Prolonged immobilization and inflammatory cytokines activate the ubiquitin-
proteasome system, autophagy-lysosome system, and other intracellular pathways
within the skeletal muscle to cause increased levels of proteolysis and catabolism,
manifesting clinically as the sarcopenia and myopathy characteristic of ICUAW
• When ICUAW involves neuropathy, this is thought to arise from microvascular
ischemia, which impairs neuronal mitochondrial function and causes
demyelination.[25] The pathophysiologic mechanisms underlying the cognitive
impairments of PICS are less well understood, but microglial activation, oxidative
stress, mitochondrial dysfunction, and activation of apoptotic pathways have all be
implicated.[8] Neuroinflammation also probably plays a role as higher levels of IL-6
and IL-10 have been associated with decreased cognitive performance up to 4
years post-ICU discharge.

Putative mechanisms of intensive care unit‐acquired
weakness

• 2.Clinical and Diagnostic evaluation of PICS
• 2.1 Clinical presentation:
• The clinical presentation of post-intensive care syndrome (PICS) includes a constellation of cognitive, psychiatric, and physical signs and symptoms
with the hallmark feature that they are newly recognized or worsened after a critical illness. Common symptoms include weakness, poor mobility,
poor concentration, fatigue, anxiety, and depressed mood, which are corroborated by examination and formal testing. Although recovery is possible,
many of the signs and symptoms of PICS last for months to years (Watson et al., 2018).
• A complex relationship exists between all three components of PICS (cognitive, psychiatric, physical), with impairment in one domain frequently
being associated with new or worsening function in a separate domain. Conversely, physical rehabilitation appears to decrease cognitive impairment
and psychiatric morbidity, as well as improve physical function (Ohtake et al., 2018).
• 2.1.1 Cognitive impairment
• The severity of cognitive impairment varies from mild to severe – from subtle difficulties in accomplishing complex executive tasks to a profound
inability to conduct one's activities of daily living. In the largest study of cognitive sequelae following critical illness, at three months 40 percent had
deficits that were similar to patients with moderate traumatic brain injury, and 26 percent had deficits that were similar to mild dementia
(Puthucheary et al., 2022).
• The areas of cognition that are commonly affected in PICS include the following:
• ●Attention/concentration
• ●Memory
• ●Mental processing speed
• ●Executive function
• (Petrinec et al., 2018)
• Memory and executive function are the most commonly affected domains that frequently prohibit individuals from engaging in purposeful, goal-
directed behaviors necessary for effective daily functioning and complex cognition.
• For example, these functions are critical to effectively carry out a discharge plan (medication adherence, dietary restrictions, scheduling and
maintaining appointments), further impairing recovery (Flaws et al., 2021).
• Impaired cognition may also contribute to communication difficulties frequently observed in patients admitted to rehabilitation following a critical
illness. Cognitive impairment is frequently unrecognized due to the inability of patients to communicate and because neither screening nor formal
testing are routinely used in clinical practice (Brown et al., 2019).

• 2.1.2 Psychiatric impairment
• Psychiatric morbidity after critical illness is often disabling and is associated with reduced quality of
life for both the patient and their family. The mood disorders most commonly encountered in
patients with PICS include anxiety, depression, and posttraumatic stress disorder (PTSD) (Landoni et
al., 2020).
• The most common symptoms of anxiety include excessive worry, irritability, restlessness, and
fatigue. Patients with symptoms of depression may complain of fatigue, loss of interest, poor
appetite, sense of hopelessness, and insomnia. Symptoms suggestive of PTSD include affective and
behavioral responses to stimuli that provoke flashbacks, hyperarousal, and severe anxiety, as well
as intrusive recollection and avoidance of experiences that evoke symptoms (Ni et al., 2022).
• Sexual dysfunction is common particularly in those with symptoms of PTSD. One prospective
observational study of 127 patients who spent more than three days in an intensive care unit (ICU),
reported sexual dysfunction in 44 percent of patients. There was a strong association between
sexual dysfunction and symptoms of PTSD but no association with age, sex, length of stay, use of
mechanical ventilation, or tracheostomy (Flaws et al., 2021).
• Survivors of critical illness may have increased risk of suicide and self-harm. Among over 420,000
consecutive ICU survivors, one retrospective study reported that survivors of critical illness had a
higher risk of suicide and self-harm compared with non-ICU hospital survivors. Factors associated
with suicide or self-harm included previous depression or anxiety, previous PTSD, invasive
mechanical ventilation, and renal replacement therapy (Inoue et al., 2019).

• .3Physical impairment
• Patients with PICS may exhibit the signs and symptoms of ICU-acquired weakness that ranges from generalized poor mobility and multiple falls to
quadriparesis and tetraparesis. These signs and symptoms frequently lead to persistent disabilities in activities of daily living and instrumental
activities of daily living (eg, ability to take medications, perform housework). Additional morbidities, which may collectively contribute to physical
dysfunction include contractures, poor lung function, and malnutrition (Ahmad et al., 2021).
• A) ICU-acquired weakness
• This group of disorders encompasses patients with ill-defined generalized muscle weakness and poor mobility as well as patients with well-defined
signs and symptoms of critical illness myopathy (CIM; flaccid quadriparesis), critical illness polyneuropathy (CIP; limb muscle weakness and atrophy),
combined CIM/CIP, and prolonged neuromuscular blockade (tetraparesis). (Pšenička et al., 2021).
• ●Contractures and limb function – Joint contractures develop as a complication of prolonged immobility. In a study of patients admitted for 14 days
or more in the intensive care unit (ICU), 34 percent of patients had a functionally significant contracture at ICU discharge, a limitation which persisted
in the majority of these patients throughout the hospitalization. The most commonly affected joints were the elbow and ankle, followed by the hip
and knee. Upper limb disability, related to shoulder impairment, is also common after critical illness. In a study of patients receiving ICU care for
three or more days, 47 percent of patients experienced upper limb dysfunction at six months (Martillo et al., 2021).
• B)Reduced lung function.
• The effect of mechanical ventilation on lung function is best studied in patients who survive acute respiratory distress syndrome (ARDS). Lung
function following ARDS is commonly compromised for as long as five years. The most common deficit is a reduction in diffusing capacity for carbon
monoxide, followed by reductions in lung volumes and spirometry. In most patients, lung volumes and spirometry will normalize by six months and
diffusion capacity should normalize by five years. Supplemental oxygen is rarely required (Inoue et al., 2019).
• C) Malnutrition
• Weight loss is common during critical illness. This is especially true in patients receiving mechanical ventilation, who often receive less than 60
percent of their daily prescribed energy requirements as a result of feeding intolerance, delays, or interruptions. In one study of 109 ARDS survivors,
patients lost 18 percent of their baseline body weight with weight gain to near normal levels by 12 months. Although the relationship is unproven,
malnutrition likely contributes to the subjective weakness reported by patients, as well as to the reduction in exercise capacity. In addition, patients
who are extubated after prolonged mechanical ventilation have swallowing dysfunction further impairing their ability to eat, thereby committing the
patient to enteral or parenteral nutrition(Colbenson et al., 2019).
• D) Poor sleep
• Sleep disturbance is common following critical illness. One review of 22 studies reported that roughly 50 to 66 percent of patients experience sleep
disturbance at one month after hospital discharge for a critical illness that improves over time (Ohtake et al., 2018).

• 2.2Diagnostic evaluation
• A high index of suspicion is critical for the identification of
post-intensive care unit syndrome (PICS). PICS is frequently
unrecognized because neither screening nor formal testing
have traditionally been used in this population. In our
practice, we follow the Society of Critical Care Medicine
(SCCM) consensus statement regarding the detection of
PICS (Marra et al., 2018).
• the SCCM advocate for early and serial assessment,
beginning at intensive care unit (ICU) admission, as part of
the ICU to floor handoff, a predischarge functional
assessment prior to hospital discharge, and then post-
discharge (ie, within two to four weeks of hospital
discharge and continued throughout recovery) (Petrinec

• This includes a thorough history and examination as well as confirmatory testing (eg, pulmonary function, neuro-electrophysiologic testing) and appropriate consultation (eg,
occupational and physical therapists, neuro-psychologists, psychiatrists) (Ramalingam et al., 2020).
• Evaluating PICS criteria — The evaluation of the three domains of PICS (cognitive, psychiatric, physical). Consistent with the SCCM consensus statement, we encourage a systematic
screening approach to identify potential long-term impairments, beginning within two to four weeks of hospital discharge (Biehl et al., 2020).
• A)Cognition
• Every patient with suspected PICS should undergo a clinical assessment and/or formal testing for cognitive deficits, when feasible. Although of unproven benefit for patients with PICS,
the rationale for this approach is based upon the benefits of cognitive rehabilitation in those with traumatic brain injury and stroke and the potential to improve executive dysfunction in
survivors of critical illness (Brown et al., 2019).
• Validated cognitive impairment screening tests usually performed at the time of hospital discharge or in the post-acute care setting that can be used for patients with suspected PICS
include:
• ●Montreal Cognitive Assessment (MoCA)
• ●Modified Mini-Mental State examination (MMSE)
• ●Mini-Cog
• (Inoue et al., 2019)
• Although MMSE and Mini-Cog are the most widely known cognitive screening tests and are the best studied in the general population in ICU survivors, neither the MMSE nor the Mini-
Cog predicted cognitive impairment at six months. We agree with the SCCM and prefer the MoCA for the evaluation of patients with suspected cognitive dysfunction following a critical
illness. This preference is based upon the observation that the MoCA, which incorporates an assessment of executive function abilities, is a more sensitive test for mild impairment.
Executive dysfunction is common amongst ICU survivors, and it is also potentially responsive to rehabilitation and compensation strategies. A MoCA score <26 indicates mild cognitive
impairment and a score <18 indicates moderate to severe cognitive impairment consistent with dementia. Whether cognitive impairment identified using the MoCA at hospital discharge
or shortly thereafter predicts long-term impairment is unknown. The evaluation of patients for cognitive impairment is discussed separately (Nakanishi et al., 2021).
•
• B) Mental health
• Every patient with suspected PICS should undergo a clinical assessment and/or formal mental health screening, when feasible. A number of validated screening tests can be used to
identify symptoms consistent with depression, anxiety, or posttraumatic stress disorder (PTSD); although none have been validated for use in PICS, the Medical outcomes Study Short
Form (SF)-26 has been studied as a possible indicator of general mental health in survivors of acute respiratory failure. A number of tools, validated in other populations, have been used
in studies of critical illness survivors and no dominant questionnaire exists. Familiarity, efficiency, and item content can be used to guide the questionnaire selected. Based upon our
clinical experience and supported by the SCCM, our preferred mental health screening scales are the following (Fuke et al., 2018):
• ●Hospital Anxiety and Depression Scale (HADS) is recommended as a single instrument to assess for symptoms of depression and anxiety. As an alternative, the Beck Depression
Inventory and Beck Anxiety Inventory may also be used (Inoue et al., 2019).
• ●Impact of Events Scale-Revised (IES-R) and the six-item Impact of Event Scale-6 (IES-6) are reliable screening tools for PTSD symptoms. Alternatively, posttraumatic stress syndrome 10-
questions inventory (PTSS-10) may be used (Hodgson et al., 2018).
• Additional tools that have been validated in other populations include the Zung depression and anxiety scales, the patient health questionnaire-2 and -9 forms, the PTSD checklist-Event
Specific Version (PCL-S), item mapping according to the Diagnostic and Statistical Manual of Mental Disorders-IV and the civilian and military PTSD questionnaire.(Ni et al., 2022).
• C)Physical impairment
• Patients should be formally assessed by a medical professional trained in the identification of ICU-acquired weakness (usually a physical therapist and an occupational therapist). This
evaluation should begin in the ICU to identify those with weaknesses who might begin therapy early in their course. Subsequently, patients should be reassessed in the rehabilitation
setting or at home to determine functional disabilities that affect activities of daily living (eg, bathing and dressing) and eating (eg, swallowing function), and disabilities that require
medical or social support (Wang et al., 2022).
• For those in whom the diagnosis of ICU-acquired weakness is suspected, formal electromyography and nerve conduction studies can confirm the diagnosis but are often not necessary,
because management is frequently unaltered by the diagnosis. Although not validated, handgrip dynamometry is a simple tool that can indicate reduced global strength in ICU patients
and may be useful to identify those at risk of ICU-acquired weakness (Martillo et al., 2021).
• Formal assessment of lung function with a full set of pulmonary function tests (spirometry, lung volumes, and diffusing capacity) should be performed in select patients as an outpatient,
particularly those who are extubated following mechanical ventilation for acute respiratory distress syndrome, or those with known underlying chronic lung disease. All mobile patients
reporting symptoms should also undergo exercise tolerance with a six-minute walk test. Full cardiopulmonary exercise testing is not typically performed (Inoue et al., 2019).
• Nutrition assessment should occur during and following ICU discharge as well as during the course of recovery to identify altering nutrition needs over time (Ahmad et al., 2021).

Evaluation
• specific post-ICU clinics are relatively common in the UK’s National Healthcare
System, this is not the case in the US, where PICS is usually best evaluated in the
primary care setting.[28] For this reason, it is imperative that primary care
providers and others who see former ICU patients in the outpatient setting be
aware of the hallmarks of PICS.
• Vanderbilt University established a post-ICU clinic, termed the ICU Recovery
Center, in 2012 to identify and treat PICS. While this model may not be feasible in
all centers, certain aspects of it may be replicable in typical primary care or post-
operative settings. The first visit typically takes place two weeks post-hospital
discharge. It includes spirometry and a six-minute walk test to evaluate for physical
impairment, screening for mental health problems, and a brief cognitive
assessment, such as the Montreal Cognitive Assessment or Mini-Mental Status
exam. In this visit, a review of the patient’s ICU course such that the patient’s
recollection of events can be reconciled with an actual timeline of events. The
developers of Vanderbilt’s ICU Recovery Center acknowledge several factors that
limit the Center’s effectiveness, including losses to follow-up and appointment no-
shows

• ICU Follow-up Clinics
• The benefits of an ICU follow-up clinic have yet to be demonstrated in terms of patient and family outcomes. Conceptually, ICU follow-up clinics are
staffed by pulmonary and critical care specialists and employ a multidisciplinary approach with extensive care coordination between physical and
occupational therapists, physical medicine and rehabilitation physicians, neurologists, and neuropsychologists (Ahmad et al., 2021).
• With regard to PICS-F, these clinics offer the potential to rehabilitate PICS, further reduce the burden of caregiving by providing optimal support for
families, explore the family experience of an ICU stay, and potentially provide education and resources to families experiencing PICS-F. Admittedly,
the potential of post-ICU clinics has not been realized. For example, a pragmatic trial of a nurse-led follow-up program designed to improve health-
related quality of life and mitigate psychological distress in survivors was neither effective nor cost-effective. However, comprehensive discharge
planning and home follow-up after an acute care hospitalization reduced hospital readmissions and healthcare costs among the elderly (Inoue et al.,
2019).
• It is conceivable that ICU follow-up clinics, designed and coordinated with optimal discharge planning for the survivor and caregivers, could improve
patient-centered outcomes such as time spent at home and ease the psychological distress of caregivers. Given the functional impairments of
survivors, which can negatively impact caregivers, timely assessment of post-acute care services and/or placement (e.g., acute rehabilitation) at the
time of hospital discharge is a potential strategy to improve outcomes for the survivor-caregiver dyad. Last, by openly eliciting the preferences and
goals of survivors, timely consideration of hospice may result in improved outcomes for some survivors and their caregivers (Watson et al., 2018).
• Given that these symptoms begin before discharge, clinicians should also consider an acute Family ICU Syndrome of psychological morbidity among
family members of their patients. Additionally, family members of patients who require prolonged mechanical ventilation and long-term acute care
hospitalization suffer psychological and physical morbidity (Hall et al., 2022).
• The COVID-19 pandemic response resulted in significant limitations on family presence. A study of family members of patients with COVID-19 found
that the majority (63.6 percent) suffered symptoms of PTSD. Limiting family presence may have also impacted care. Acknowledging that limiting
family presence may be an infection prevention measure, it is an ethical imperative that family members support their loved ones, both for the
patient's benefit as well as the family's. When presence may be limited (but not eliminated), telephone and teleconferencing families to their loved
ones may be of benefit, though outcome data are limited (LI et al., 2018).

• Several groups have developed questionnaires to aid in the
detection of PICS in the outpatient setting.[30][31] An
advantage of these screening questionnaires is that they
can be administered remotely as transportation to
outpatient clinics is often a problem for recovering ICU
patients. Some authors have also reported success in
utilizing telemedicine to evaluate patients for symptoms of
PICS remotely.[32] Other aspects of evaluation require
inpatient visits, for example, electromyography and nerve
conduction studies can help to distinguish myopathy and
neuropathy from generalized weakness, as the PT/OT
approaches to address these conditions are different.[3]

• The most effective strategy to prevent PICS is to prevent critical illness. For
example, public health measures (eg, masking) and vaccination reduce the
transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and
thereby reduce the risk of hospitalization or death related to COVID-19. In patients
with moderate to severe acute hypoxemic respiratory failure, the use of high-flow
oxygen therapy, compared with standard oxygen therapy, reduces the need for
invasive mechanical ventilation and the inherent harms associated with its use
(Inoue et al., 2019).
• Once critical illness has developed, the most effective strategy to prevent PICS is
one that minimizes sedation and prioritizes early physical rehabilitation during the
intensive care unit (ICU) stay and continuing through the recovery process. While
cognitive rehabilitation may prove to be of benefit in conjunction with physical
therapy, further study is required to examine the efficacy of this approach (Ohtake
et al., 2018).
• The management of PICS focuses on treating individual impairments (cognitive,
psychiatric, physical) with additional referral to appropriate health care personnel,
when necessary. A multidisciplinary team approach with a clinician responsible for
coordinating care is critical to the successful management of PICS (eg, primary care
clinician, physical rehabilitation clinician)

• 3.1 Prevention and treatment
• To minimize the likelihood of developing PICS in critically-ill patients, particularly in
those receiving mechanical ventilation, we prefer the ABCDEF bundle
approach(Figure 8) that promotes the following strategies (Watson et al., 2018):
• ●Awakening and Breathing Coordination with daily sedative interruption and
ventilator liberation practices
• ●Delirium monitoring and management
• ●Early ambulation in the ICU, when feasible
• ●Family empowerment and engagement
• (Jong et al., 2020)
• In addition, the clinician should provide care known to optimize neurologic
outcomes including light sedation practice, and avoiding hypoglycemia and
hypoxemia, when feasible. The best level of evidence to support this practice is
derived from a prospective cohort study of over 15,000 ICU adults, which reported
that use of the ABCDEF bundle was associated with a lower likelihood of death
within seven days, mechanical ventilation, and coma, as well as delirium, physical
restraint use, and ICU readmission

ABCDEFGH bundle for prevention of post-intensive care syndrome

• A)Physical rehabilitation
• The main purpose of rehabilitation in the ICU is to improve the quality of life by maintaining, improving, and reacquiring activities of daily living. Both
ICU-AW and delirium, as parts of PICS, are related to a decreased quality of life. The Japanese Clinical Practice Guidelines for Management of Sepsis
and Septic Shock 2016 suggested implementing early-stage rehabilitation as a PICS preventative measure for sepsis or ICU patients. Physical
rehabilitation in the ICU could improve mobility status and muscle strength. (El-Hady et al., 2020).
• The definition of “early” in early rehabilitation practice usually refers to intensive physical rehabilitation that is implemented in addition to regular
care at any time during an ICU stay. The term “early” has yet to be defined as, among various studies, the onset of interventions could vary by as
much as 1 week.(Nakanishi et al., 2021).
• Physical rehabilitation for mobility includes activities such as sitting, standing, and ambulation, as well as passive exercises including range-of-motion
exercises and ergometers. An ICU survey in Japan revealed that sitting on the edge of the bed was routinely provided in ICUs, whereas
neuromuscular electrical stimulation and a cycle ergometer were rarely provided. (Lee et al., 2020).
• B)Nutrition
• Nutritional therapy is vital for the prevention of PICS, especially ICU-AW.(Figure 9) Adequate energy delivery and protein intake are the most
important factors for muscle synthesis; moreover, energy debt is covered by catabolism mainly of the muscle, which is associated with lean body
mass loss related to risk mortality. Previous studies on nutrition therapy targeted mortality and infectious complications as outcomes. With the
recent opinion that nutrition therapy should target muscle volume and strength, there is a strong connection between nutritional therapy and PICS.
Although studies have shown that the securement of minimum energy delivery with supplemental parenteral nutrition from the acute phase was
associated with decreased PICS, overfeeding could induce autophagy impairment and worsen ICU-AW (Brown et al., 2019).
• Therefore, we should target appropriate energy delivery and avoid overfeeding. Adequate protein delivery with total energy could reduce
PICS; however, a number of studies have reported that protein delivery alone does not reduce PICS. As muscle protein synthesis is maximized with
appropriate exercise in healthy individuals, not only nutrition therapy alone but also appropriate exercise and rehabilitation together with adequate
nutrition are also necessary in critically ill patients as for the particular kind of nutrition, leucine is the amino acid reported to induce muscle protein
synthesis. Unfortunately, administration of specific amino acids including leucine has not shown efficacy in critical care. Approaches to enhance
anabolic power, such as β-hydroxy-β-methyl-butyrate or oxandrolone, remain to be examined for the prevention of PICS and ICU-AW

Association between critical illness and intensive care unit-acquired weakness (ICU-
AW)/post-intensive care syndrome (PICS) and the importance of nutrition therapy and
rehabilitation. Malnutrition and inactivity accelerate ICU-AW/PICS, especially with
skeletal muscle volume and strength/functional loss. Nutrition therapy and rehabilitation
are essential factors and the basis for the prevention of PICS/ICU-AW

• C) Environmental management for healing
• Patients admitted to the ICU experience environmental stimuli, particularly noise and light. Excessive noise in the ICU has been reported in numerous studies (Jong et al., 2020).
• A recent observational study in six ICUs suggested that background noise had a negative impact on sleep quality. Five RCTs examined the effects of noise reduction devices such as
earplugs and noise-canceling headphones combined with or without eye masks on sleep quality among patients in the ICU (Lee et al., 2020).
• All RCTs reported better perceived sleep quality in patients with the devices; however, three of five studies were carried out mainly in post-surgical patients and one was for non-
ventilated, mostly cardiac patients. Thus, these findings did not have external validity to generalize to all ICU patient populations. Improved sleep quality by using noise reduction devices
could reduce the development of delirium in the ICU (Manning et al., 2018).
• Little is known about the contribution of environmental factors to the mental health of patients after intensive care. One RCT reported that music therapy or noise-canceling headphones
reduced anxiety during ICU stay compared to usual care in patients with respiratory failure requiring mechanical ventilation. These interventions could affect the symptoms of mental
health after intensive care, despite the lack of verification (Major et al., 2021).
• D) Nursing care for PICS
• One of the most important roles of nurses is the continuous implementation of measures to prevent PICS, including the ABCDEFGH bundle. Nurses spend most of their time on direct
patient care. In addition to optimal analgesia, nurses can support safe light sedation by staying near patients. Through light sedation, patients can prepare to satisfy the higher levels of
human needs (Heydon et al., 2020).
• To understand and address the patient's needs, nurses need to know the patient's living conditions prior to hospitalization. Nurses should assess gaps between the patient's
prehospitalization and current functional abilities and should support functional reconciliation. Non-pharmacological interventions can also be important to restore the patient's ordinary
daily function in the hospital environment. Family involvement also plays a key role. The provision of information, including PICS, to family members and using an ICU diary can
strengthen the connection between the patient and family members and medical staff. Moreover, it can also promote family participation in patient care. Early rehabilitation and
mobilization interventions can improve physical function in patients with critical illness (Jia et al., 2019).
• Furthermore, short-term, and high-frequency rehabilitation and mobilization interventions can improve the functional ability of patients. Nurses facilitate patient mobility at all hours of
the day and night and, therefore, could contribute to improving patient functional ability. The recovery process from PICS is a continuum. Functional reconciliation requires continuous
and consistent care even after ICU discharge. Thus, good handoff communication including information about PICS is necessary to achieve this consistent care (Flaws et al., 2021).
• E) Intensive care unit diaries
• Intensive care unit diaries are completed by doctors and families of patients to record the patient's status while in the ICU and are kept describing the patient's experiences. The ICU diary
is written for the patient by a family member or a medical person, such as a nurse, but could also be recorded by the patient. The ICU diaries can help to indicate the orientation of the
patient, and could prevent PICS by alleviating anxiety, depression, and PTSD symptoms. Keeping a diary has been shown to reduce PTSD symptoms not only in patients but also in their
families (Ahmad et al., 2021).
• In these facilities, the nursing teams in charge, mainly the main bedside nurse, determine whether an ICU diary is appropriate. If the diary is judged to be useful, then the concept is
explained to the patient and their family, and the diary is started after obtaining their consent. The diary is used to periodically record general notes on events and daily occurrences, the
patient's life, rehabilitation situation, etc. at the discretion of the nurse in charge. If desired, it can also include photographs. The doctor in charge, physical therapist, and clinical
engineering technicians involved in care might also add to the diary. The diary is presented to the patient at ICU discharge (Brown et al., 2019).
• Diaries can foster the formation of factual memories, lost by the patient during their ICU stay. However, while small prospective or randomized studies have shown that the use of an ICU
diary maintained prospectively during the patient's ICU stay by family members, health care providers, or both decreases symptoms of posttraumatic stress disorder (PTSD), (Colbenson
et al., 2019).
• F)Intensive care unit follow-up clinics
• Intensive care unit follow-up clinics are specialized clinics for patients who have survived and been discharged from the ICU. They have attracted attention as a place for the diagnosis and
treatment of PICS. (Marra et al., 2018).The clinics have been developed mainly in Europe; however, their format and methods for patient evaluations have not been adequately studied
and vary between facilities. There is also insufficient evidence regarding the usefulness of ICU follow-up clinics; therefore, further verification is necessary for future development
(Heydon et al., 2020).

• G) Established Therapy for PTSD
• Many modalities of therapy have been established and researched that reduce the symptoms of PTSD. Such therapies include interpersonal, behavioral, technological, pharmacological, and
musical, all of which may be incorporated into a treatment plan individually or in combination (Edmondson et al., 2012). The effectiveness of the selected therapy, or combined therapy efforts,
depends in part on the individual and their specific circumstances and symptoms. Variables such as age, gender, and proximity to trauma must be considered in the diagnosis and treatment of
such disorders. Therefore, there is not one exclusive method for treating all patients with PTSD, but rather a range of established treatment options that may be recommended depending on
physician discretion.(Watts et al., 2013)
• Behavioral Therapy
• Behavioral therapy, specifically individual cognitive behavioral therapy (CBT), is a commonly prescribed treatment option for patients with PTSD. This approach addresses a patient’s cognition or
thought patterns, as well as behavior, or patterns of action. Mental healthcare professionals work with patients to understand their impaired thoughts, often attached to traumatizing memories
and stimuli, and adjust their thinking to encourage healthy thoughts and emotional expression. This therapy aims to teach coping skills so that patients can manage and reduce symptoms on
their own. In modifying the thoughts, emotions, and behaviors of an individual, this method minimizes the tendency of distorted cognitions to manifest as damaging behaviors. The category of
behavioral therapy also encompasses eye movement desensitization and reprocessing (EMDR). This form of psychotherapy incorporates exposure to triggering stimuli and uses eye movements
to allow a patient to experience their symptoms of fear and anxiety, understand the roots of such emotions, and begin to store memories of their experiences with a new and more positive
perspective. Practices such as mindfulness, yoga, and acupuncture are also considered behavioral therapies that can aid in the management of PTSD symptoms and are especially popular in
Eastern cultures (Cukor et al., 2009).
• CBT is typically administered over a period of months or years and, while an extensive time commitment, can offer a gradual path to healing via consistent support and guidance. When
assessing treatment options for PTSD, cognitive behavioral therapy is generally considered efficacious. Especially in initiating cognitive recovery, CBT has proven to be a crucial step in adjusting
distorted cognitions and redirecting behaviors. While CBT is beneficial to many. In patients that exhibit extreme amygdala activity, CBT is far less effective in providing coping skills. In patients
who were less receptive to this treatment, the amygdala, or the component of the brain responsible for regulating fear, experienced an abnormal surge of activity in response to the
presentation of feared stimuli. This is assessed via fMRI, or functional magnetic resonance imaging. Therefore, individual differences must be considered when devising an individualized
treatment plan to treat PTSD. The implications on PICS are comparable to those of PTSD, as patients in the ICU are exposed to trauma and experience similar symptoms that impair cognition and
behaviors.(Bryant et al., 2008)
•
• Technological Therapy
• Technological therapy can be used to describe treatment that is implemented through technology. Internet-based therapy provides a treatment option for patients who are geographically
isolated or hindered from obtaining in-person treatment due to fear of stigmatization. However, technological therapy often requires access to computers and various electronics, which creates
a barrier to those with financial limitations. Patients with such limitations are able to receive coaching and gain access to mental healthcare professionals. New technologies also allow for the
exploration of virtual reality. This mode of therapy immerses the patient in a sensory experience that mimics their trauma, which can be recreated in a visual, auditory, or haptic manner.
Repeated exposure to a given feared stimulus can allow for an individual to manage their emotions surrounding the traumatic experience. Facing such anxiety in a safe environment supports a
decrease in stress and increase in emotion management.(Cukor et al., 2009).
•
• Pharmacological Therapy
• Pharmacological therapy is commonly used in symptom management for PTSD and psychological disorders. The primary focus of pharmacological therapy is on antidepressant medication, with
an emphasis on selective serotonin reuptake inhibitors (SSRIs) (Watts et al., 2013). While cognitive behavioral therapies have a greater long-term efficacy, medications can be crucial in creating
stability and reducing anxiety while a permanent treatment plan is established. Other varieties of medication have also been considered as an option in the prevention and treatment of
PTSD. Propranolol, a beta-adrenergic blocker, acts as a protective measure against the onset of PTSD. As it blocks the reception of the neurotransmitter epinephrine, it allows memories to be
stored with less emotional stress. This dissociation between memory and emotion may help reduce symptoms in PTSD patients. Prazosin, an alpha-1 adrenergic blocker, works to block excess
norepinephrine, a neurotransmitter commonly released at night and correlated with nightmares. This medication may be beneficial in treating patients experiencing frequent flashbacks and
nightmares. Because PTSD symptoms stem from a fear response, medication can be ineffective in the presence of traumatic stimuli. Although pharmaceuticals do not address the psychological
origins of PTSD, they assist in symptom management for many patients (Cukor et al., 2009).
•
• Group Therapy
• Group therapy is often used in the treatment of PTSD and other psychological disorders to emphasize the importance of social relationships in recovery and promote interpersonal connection.
Additionally, it identifies the direct impacts of trauma on such relationships and aids in mending or strengthening them. The family members of patients with PTSD often experience deep grief
that can evolve into depression or anxiety. This mode of relational therapy can help both patients and their family members cope with the traumatic experiences that led to PTSD, as well as
manage the symptoms of PTSD in a way that fosters healthy relationships. Similarly, families of ICU patients experience distress and can benefit from participating in group therapy. Group
cognitive behavioral therapy (GCBT), while not as well researched as individual cognitive behavioral therapy (CBT), is also used in treatment plans for PTSD patients. This approach teaches skills
that allow patients to regulate their symptoms of stress and anxiety. The group context in which these skills are introduced allows for a collaborative learning environment and provides a more
cost-efficient alternative to individual CBT. While the focus of group therapy supports a patient’s social relationships, GCBT offers cognitive skills and training in a way that can also facilitate
personal connection with others. (Watts et al., 2013)

Treatment / Management
• Unfortunately, the efficacy of post-ICU clinics and other services to address the
Post Intensive Care Syndrome (PICS) once it has occurred is modest at best. For
example, a recent Cochrane Review of studies investigating the impact of ICU
follow-up services found limited effectiveness in terms of improving health-related
quality of life (HRQoL).[33] Therefore, the best treatment for the PICS syndrome is
preventative measures that are initiated immediately in the ICU setting. The
ABCDEF bundle of care is an evidence-based approach to preventing PICS and is
being incorporated into the ICU care at over 70 major hospitals throughout the US
as part of the ICU Liberation Collaboration:[34]
• A- Assessment, management, and prevention of pain
• B- Both spontaneous breathing trials and spontaneous awakening trials
• C- Choice of sedation and analgesia (maintain a relatively light level of sedation
and avoid benzodiazepines)
• D- Delirium assessment, prevention, and management
• E- Early mobility and exercise
• F- Family engagement and empowerment

• Collectively, these measures address the physical impairments of PICS by preventing immobility and
prolonged mechanical ventilation, the cognitive impairments by minimizing the exposure to
sedatives and preventing delirium, and the mental health impairments by promoting patient-
centered care. One well-studied method to address the mental health aspects of PICS and PICS-f is
the use of ICU diaries, written chronological accounts of the ICU stay, often with accompanying
pictures, that are shared with survivors and their family members during and after the ICU stay.
Because ICU patients often have limited or distorted memories of their ICU experience due to
sedation and delirium, these diaries can be re-orienting and serve as an enduring reminder of the
patient’s medical progress. A meta-analysis found that the use of ICU diaries was associated with a
decreased incidence of depression and anxiety in ICU survivors, while HRQoL scores also improved.
ICU diaries also reduced the risk of PTSD in family members, but the evidence supporting this
conclusion was not as robust.[35]
• Quality communication between the ICU team and family members is also thought to decrease the
risk of PICS-f. This can be achieved by regularly scheduled family conferences, strategies of
empathic listening, avoidance of medical jargon, and the involvement of social workers,
psychotherapists, and clergy members.[18] A recent study also found decreased rates of PTSD in
family members who participated in a novel approach that included direct participation in bedside
care rituals for the ICU patient.[36]

• The ICU Diary
• The ICU diary is a promising tool for reducing symptoms of
PICS and PICS-F. The diary consists of a notebook composed
of recorded events from a patient’s ICU stay, written in
simple, understandable language. Family members or
nurses most commonly populate the contents of the ICU
diary, with the intention of reviewing the events of an ICU
stay with the patient following their discharge and allowing
the patient to realign periods of confusion or inaccurate
memories of their ICU stay with the reality of these events.
The diary may be reviewed with the patient after discharge
in the presence of a primary care provider, a family
member educated in the use of the diary, or an ICU follow-
up clinic provider

ICU Diaries Starting a Diary Program
ICU Diaries Starting a Diary Program
Key requirements for starting
Legal Team / Guardian approval
Diary notebooks
Polaroid camera or digital camera with printer - Memory
card wiped after printing
Diary register
Enable tracking of which patients have a diary and where
the diary currently is located
Secure, lockable storage
Storage of diaries between patient discharge and follow-up
Diary guidelines at every bed space
Diary champions

ICU Diaries http://www.icu-diary.org/
Idea originated in Scandinavia
Written for ICU patients during their time of sedation and ventilation.
Daily account of ICU stay in every day language
It is written by relatives, nurses and others in plain language
•Photograph of patient taken at start and points of change
The patient can read his or her diary afterwards and is more able to
understand what has happened.
Aim to fill in memory gaps and help patients understand their illness
With staff support to go through the diary and photos
UK National Institute for Health and Clinical Excellence recommend
cognitive behavioural therapy (CBT for PTSD). Changing how clients think
about their traumatic experience is one of the aims of CBT

Early ICU psychological Intervention
Careggi University Hospital, Florence
Clinical Psychologist provide emotional
support, educational interventions, & stress
management coping strategies to trauma
patients & families
Available 24 hours
Observational study of those with and
without a clinical psychologist
A trend towards less depression and anxiety
A statistically significant decrease in PTSD
(21.1% vs. 57.%)

Differential Diagnosis
• (PICS) is a complex disease process that overlaps with many other disorders.
• The physical impairments of PICS should be differentiated from other causes of weakness or
neurological deficit, including stroke or disorders of the spine.
• Electrolyte, endocrine, or nutritional deficiencies giving rise to these symptoms should also be
ruled out and addressed.
• While cognitive decline resulting from PICS should be differentiated from other causes of dementia,
there may be overlap between the two, particularly in elderly populations. While the course of
different forms of dementia, such as Alzheimer is typically progressive, cognitive impairments
arising as part of PICS tend to be more stable over time. Additionally, memory deficits are usually
less pronounced in PICS than in other dementia syndromes, while attention and processing speed
are more significantly impacted.
• Severe depression, which may be a component of PICS, can also masquerade as cognitive decline
with pronounced deficits in attention and concentration. It is essential to distinguish between the
two as the former is amenable to antidepressants and psychotherapy while the latter is not.
• The mental health manifestations of PICS-f are similarly complex and may exist within the context
of other life-long psychiatric diagnoses. Providers treating these patients should also entertain the
possibility of organic sources of these problems and not merely ascribe them entirely to the
experience of having had a loved one in intensive care.

• 3 Differential diagnosis
• 2.3.1 Pre-existing illnesses – The presence and severity of prior existing cognitive, mental, or physical impairments needs to be evaluated to identify unchanged, as well as, new or
worsening symptoms following a critical illness, all of which can impede a meaningful and sustained recovery. Compared with new or worsening symptoms, unchanged symptoms do not
support a diagnosis of PICS. Examples of pre-existing illnesses include prior cognitive deficits from developmental defects, dementia or traumatic brain injury, anxiety or panic disorder,
depression or schizoaffective disorder, substance abuse, failure to thrive, and neuromuscular disorders such as multiple sclerosis and amyotrophic lateral sclerosis (Colbenson et al.,
2019).
• 2.3.2Organic causes of symptoms that mimic PICS
• Conditions, including stroke, hypothyroidism, hyperthyroidism, vitamin B12 deficiency, anemia, cancer, and obstructive sleep apnea occasionally mimic the cognitive, psychologic, and
neuromuscular weakness manifestations of PICS. Some of these organic causes may be obvious on routine laboratory testing or imaging obtained during the ICU stay. Alternatively,
others are more subtle (eg, sleep apnea) (Brown et al., 2019).
• Testing for organic pathology should be directed by clinical history and examination or prompted in those who respond atypically to rehabilitation. Laboratory and imaging studies that
are routinely obtained following a critical illness include a complete blood count and differential, chemistries, iron, and vitamin B12 levels, thyroid stimulating hormone, liver function
tests, and chest radiography. Additional testing can be directed by clinical suspicion and may include computed tomography or magnetic resonance imaging of the brain, or a sleep study
(Stam et al., 2020).
• 2.3.3Muscle weakness disorders other than ICU-acquired weakness
• Conditions including rhabdomyolysis, cachectic myopathy, and Guillain-Barré syndrome may be confused with ICU-acquired weakness. However, they are usually obvious on admission or
identified as the initiating reason for ICU admission and therefore, do not qualify as PICS. Although not frequently performed, neuromuscular disorders are usually distinguished from one
another by laboratory and electrodiagnostic findings and occasionally by muscle biopsy. The indication for testing is usually dependent upon the identification of a disorder where
management other than physical rehabilitation will affect the outcome (eg, glucocorticoids for polymyositis) (Biehl et al., 2020).
• 2.3.4post-hospital syndrome
• PICS appears to be distinct from hospitalization-associated disability (also known as "post-hospital syndrome"). Hospitalization, particularly in older patients, can be associated with a
number of functional disabilities which are often transient (days to weeks). In contrast, the manifestations of PICS are wide-ranging and are typically enduring rather than transient
(Marra et al., 2018).
•
• 2.4 post-intensive care syndrome in pediatrics
• Several large critical-care databases have revealed mortality rates of critically ill children of approximately 2–4% in ICUs in developed countries, indicating that most of these children
survive. However, some of these pediatric survivors experience long-term morbidity associated with their critical care (Heydon et al., 2020).
• The rate of acquired functional impairment ranged from 10% to 36% at ICU discharge and from 10% to 13% after 2 years. They also extracted risk factors for acquired functional
impairment, including illness severity, the presence of organ dysfunction, length of ICU stay, and younger age (Watson et al., 2018).some PICU survivors subsequently died after their
hospital discharge and developed new morbidity even 3 years later. With a focus on specific diseases and conditions, (Jaffri et al., 2020).In 2018, the framework of pediatric PICS (PICS-p)
was conceptualized. The fundamental framework was similar to that of adult PICS, with several unique features (Major et al., 2021).
• First, the most important viewpoint is that children's critical illness occurs during the dynamic process of their growth and maturation and that both their outcomes and their family's
response (i.e., their parents and siblings) can interdependently influence their subsequent development and quality of life. Second, PICS-p includes a “social health” domain for children
and their families in addition to the three conventional domains of physical, cognitive, and emotional health.(Figure 7) Critical illness affects the social functioning of both children and
their families; that is, reintegration with their friends at school, their social capital, and their parents' unemployment while caring for a sick child. These social health impairments,
intertwined with morbidity in other health domains, can negatively impact their development and survival quality (Inoue et al., 2019).

Proposed framework for post-intensive care syndrome in pediatrics (PICS-p). Compared to
the concept of PICS for adult intensive care unit survivors, the unique features of PICS-p
include the importance of baseline status, system maturation and psychosocial
development, stronger interdependence within the family, and recovery trajectories that
can potentially impact a child's life for decades (

Prognosis
• The long-term prognosis of Post Intensive Care Syndrome (PICS) is highly variable. It depends
mainly on the severity of critical illness, degree of impairment at hospital discharge, and preexisting
functionality. The physical impairments of PICS are more amenable to improvement, particularly
with the use of PT/OT, while the cognitive and mental health problems may be more persistent. The
study by Marra et al. of 406 US ICU survivors found that while the rate of physical impairment
improved from 23% to 17% between 3- and 12-months post-discharge, improvements in the
cognitive or mental health domains were more modest with roughly a third of patients
experiencing deficits at both time points.[20]
• Cognitive deficits have been reported in 25% of ARDS survivors six years post-discharge, with
similarly high rates of persistent cognitive impairment observed in the sepsis population as
well.[18] While cognitive deficits following ICU recovery may be similar in magnitude to those
noted in other forms of dementia such as Alzheimer disease, the course of ICU acquired cognitive
deficits is usually not progress and sometimes may even improve over time.[8]
• Although the literature regarding the prognosis of PICS-p is sparse, it appears that the rate and
persistence of deficits in pediatric ICU survivors are similar to those in the adult
population.[37] While PICS-f is quite common in the close family members of ICU patients, the
mental health impacts usually lessen naturally with time, and improvements can be further
augmented with psychotherapy and sometimes medication.[14]

• 3.3Prognosis
• The long-term prognosis of Post Intensive Care Syndrome (PICS) is highly variable. It depends mainly on the severity of critical illness, degree of
impairment at hospital discharge, and preexisting functionality. The physical impairments of PICS are more amenable to improvement, particularly
with the use of PT/OT, while the cognitive and mental health problems may be more persistent. The study by Marra et al. of 406 US ICU survivors
found that while the rate of physical impairment improved from 23% to 17% between 3- and 12-months post-discharge, improvements in the
cognitive or mental health domains were more modest with roughly a third of patients experiencing deficits at both time points (Manning et al.,
2018).
• Cognitive deficits have been reported in 25% of ARDS survivors six years post-discharge, with similarly high rates of persistent cognitive impairment
observed in the sepsis population as well. While cognitive deficits following ICU recovery may be similar in magnitude to those noted in other forms
of dementia such as Alzheimer disease, the course of ICU acquired cognitive deficits is usually not progress and sometimes may even improve over
time (Ramalingam et al., 2020).
• Although the literature regarding the prognosis of PICS-p is sparse, it appears that the rate and persistence of deficits in pediatric ICU survivors are
similar to those in the adult population. While PICS-f is quite common in the close family members of ICU patients, the mental health impacts usually
lessen naturally with time, and improvements can be further augmented with psychotherapy and sometimes medication (Lee et al., 2020).
•
• 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 (Colbenson et al., 2019).
• 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 (Major et al., 2021).

Complications
• The long-term socioeconomic impacts of Post Intensive Care Syndrome (PICS) and
PICS-f are substantial with patients and their family members often unable to
return to full employment. A study of ICU survivors in the UK found that at one
year post-discharge, 22% still required aid with daily care ant that usually this was
accomplished by unpaid family members. Subsequently, 28% of those in the study
reported a negative impact on family income as a result of the ICU stay and
recovery.[38] A similar survey conducted in the United States found a decrease in
employment affecting 50% of ICU survivors, with half of those being newly
unemployed.[39] Family members experiencing mental health problems
associated with PICS-f not only face declines in outside employment but may also
lack the resiliency to be active caregivers for their relatives who often require
assistance long after the ICU discharge.[40]
• The lingering effects of PICS are particularly disruptive to the cognitive, social, and
emotional development of pediatric ICU survivors, while their families are also
profoundly impacted. Not only are there economic consequences as parents must
cut back on work hours to care for their ailing child, but parents also have
insufficient time and emotional reserve to attend to other siblings in the
household fully. It is for this reason that the fourth domain of social health has
been incorporated into the PICS-p framework

• 3.2 Complications
• The long-term socioeconomic impacts of Post Intensive Care Syndrome (PICS) and PICS-f are
substantial with patients and their family members often unable to return to full employment. A
study of ICU survivors in the UK found that at one-year post-discharge, 22% still required aid with
daily care and that usually this was accomplished by unpaid family members. Subsequently, 28% of
those in the study reported a negative impact on family income as a result of the ICU stay and
recovery. A similar survey conducted in the United States found a decrease in employment affecting
50% of ICU survivors, with half of those being newly unemployed. Family members experiencing
mental health problems associated with PICS-f not only face declines in outside employment but
may also lack the resiliency to be active caregivers for their relatives who often require assistance
long after the ICU discharge (Petrinec et al., 2018).
• The lingering effects of PICS are particularly disruptive to the cognitive, social, and emotional
development of pediatric ICU survivors, while their families are also profoundly impacted. Not only
are there economic consequences as parents must cut back on work hours to care for their ailing
child, but parents also have insufficient time and emotional reserve to attend to other siblings in
the household fully. It is for this reason that the fourth domain of social health has been
incorporated into the PICS-p framework (Petrinec et al., 2018).

Deterrence and Patient Education
• Implementation of the ABCDEF bundle of care within the ICU
setting can mitigate the development of Post Intensive Care
Syndrome (PICS). Improved patient handoffs that focus on
functionality, in addition to the traditional organ systems-based
approach can also likely enhance the continuity of care that ICU
patients receive during the remainder of their hospital stay and
recovery period. Identification of persistent deficits as a result of
PICS is often made in the outpatient setting, so primary care
providers must be aware of this syndrome so that patients can be
appropriately referred for follow-up services. Debriefing patients
and family members at the time of ICU or hospital discharge is also
essential as most members of the lay public are unaware of the
signs of PICS.[1] Given the high incidence of mental health sequelae
in ICU survivors and their family members, routine referral to low-
cost, accessible psychotherapy service is not unwarranted.

Pearls and Other Issues
• The novel coronavirus that emerged in Wuhan, China, in December 2019 and subsequently spread
worldwide as a pandemic has uniquely challenged healthcare systems globally.Epicenters of the
COVID-19 pandemic, including Wuhan, northern Italy, and the New York City area, have already
seen their ICU resources stretched to the near breaking point. While only a few of those infected
will require ICU care, due to near-universal susceptibility, this total number of COVID-19 patients
who will need such resources before a vaccine or definitive therapy are developed vastly. It can be
predicted that COVID-19 ICU patients will be particularly susceptible to the impairments of Post
Intensive Care Syndrome (PICS). Adherence to the ABCDEF bundle of care is challenging, if not
impossible when ICUs become overwhelmed. Further, COVID-19 ICU patients have unusually high
incidences of delirium due to the presence of encephalopathy, sepsis, and the need for prolonged
mechanical intubation inherent to the disease.[41] While the long-term consequences of COVID-19
remain unknown, the demand for rehabilitation services for these patients is likely to be high.[42]
• To minimize the transmissibility of the novel coronavirus in hospital systems, many institutions have
employed extremely restrictive patient visitation policies such that most COVID-19 patients spend
the majority of their hospitalization in near-complete isolation. While these measures are
understandable and necessary, the mental health consequences for both patients and their families
are likely to be substantial. Primary care providers and others working in the outpatient setting
should be prepared to screen COVID-19 ICU survivors and their family members for the mental
health impairments of PICS, including PTSD. Hospital systems should develop plans to minimize the
isolation of COVID-19 infection through the use of telemedicine mental health services and
technologies to facilitate virtual visitation with family and friends.

Enhancing Healthcare Team
Outcomes
• Successfully implementing the ABCDEF bundle of care to prevent the development
of Post Intensive Care Syndrome (PICS) necessitates a multidisciplinary approach.
Practical assessment and management of pain may incorporate pain management
teams. The use of regional or neuraxialanesthesia for the management of acute
pain can spare the sedating effects of opiates. Implementation of spontaneous
breathing trials and spontaneous awakening trials requires the participation of
both respiratory therapists for execution and nurses for monitoring.
• Similarly, minimizing excess sedation requires buy-in from nursing teams and may
benefit from the involvement of hospital pharmacists in the appropriate selection
of agents. Practical delirium assessment and management involves the entire team
and may incorporate design considerations, such as the presence of windows in
patient rooms to allow for natural lighting. Early mobility and exercise of ICU
patients are essential. Still, very taxing on nursing staff, and institutions must be
prepared to support nursing teams with other staff members who can facilitate
early mobilization while minimizing fall risk. Successfully engaging family members
requires frequent structured communication from ICU physicians and the use of
translation services when necessary. Patient advocates, clergy members, and other
hospital representatives from outside the ICU can also aid in maintaining clear
communication with family members

Conclusions
Post ICU syndrome is common
Can happen in families and survivors
Depression and anxiety predominate mental
health problems
PTSD can be as high as 1 in 4
Delusional memories seem to play a role
ICU diaries may help remove delusional
memories
In ICU psychology support and post ICU clinics
show promise for reducing PICS symtoms

• Conclusion
• In conclusion, although mortality of ICU patients has
declined significantly in recent decades, morbidity after
admission remains a significant issue. Certain preventative
measures during ICU admission and rehabilitation efforts
after admission show promise in reducing cognitive and
physical consequences in ICU survivors. Post-ICU clinics
have the potential to diagnose and treat deficits from ICU
illness early, but at this time their efficacy has not been
shown to be significantly better than the standard of care.
Awareness of how to identify and manage PICS deficits is
sorely needed among the clinicians who evaluate ICU
survivors .

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