Post-intensive Care Syndrome Millions of patients are admitted to intensive care units (ICUs) each year, one third of whom need a machine to help them breathe (ventilator). These critically ill patients may develop health problems related to their illness, injury, ventilator or other treatments. Such problems cannot be totally prevented and can continue after the patient leaves the hospital. Delirium, acute respiratory distress syndrome, and sepsis increase the chances of these problems occurring. They, too, may not always be prevented. If you are an ICU patient or family member, this guide helps you understand the health problems known as post-intensive care syndrome, or PICS, so you know what to look for when you return home. It also includes tips on how to minimize PICS. Many people develop PICS, and help is available. You will have the best chance of recovery if you explain your health problems to your primary care doctor, who can refer you to the specialists you need. What Is PICS? Post-intensive care syndrome, or PICS, is made up of health problems that remain after critical illness. They are present when the patient is in the ICU and may persist after the patient returns home. These problems can involve the patient's body, thoughts, feelings, or mind and may affect the family. PICS may show up as an easily noticed drawn-out muscle weakness, known as ICU-acquired weakness; as problems with thinking and judgment, called cognitive (brain) dysfunction; and as other mental health problems. ICU-acquired weakness ICU-acquired weakness (ICUAW) is muscle weakness that develops during an ICU stay. This is a common problem of being critically ill and occurs in: 33% of all patients on ventilators 50% of all patients admitted with severe infection, which is known as sepsis Up to 50% of patients who stay in the ICU for at least one week Patients who develop ICUAW may take more than a year to recover fully. ICUAW makes the activities of daily living difficult, including grooming, dressing, feeding, bathing and walking. ICUAW may greatly delay the patient from doing activities in the way he or she used to do them. Cognitive or brain dysfunction This refers to problems connected with remembering, paying attention, solving problems, and organizing and working on complex tasks. After leaving the ICU, 30% to 80% of patients may have these kinds of problems. Some people improve during the first year after discharge from the hospital; other people may never fully recover. Cognitive dysfunction may affect whether the patient can return to work, balance a checkbook, or perform other tasks that involve organization and concentration. Other mental health problems Critically ill patients may develop problems with falling or staying asleep. They may have nightmares and unwanted memories. Reminders of their illness may produce intense feelings or strong, clear images in their mind. Their reactions to these feelings may be physical or emotional. Patients may

1. Post-Intensive Care Syndrome
(PICS ) CONCEPTS &UPDATES
Dr: Ahmed Hamdy
Lecturer of Anesthesia and Intensive Care - Benha University

2. THE AGENDA
2
•
* INTRODUCTION
* DEFINITION
* EPIDEMIOLOGY
* RISK FACTORS
* CLINICAL MANIFESTATION
* EVALUATION AND DIAGNOSIS
* MANAGEMENT ( PREVENTION AND TREATMENT)
* RECENT UPDATE
* HOME MESSAGES
•

3. 26 August 1952

5. Attendees of a 2010 meeting of the Society of Critical Care Medicine coined the
term Post Intensive Care Syndrome (PICS)
PICS was created with multiple objectives, including:
(1) to raise awareness among clinicians, patients/families and the
general public
(2) to increase screening for specific impairments occurring after
critical illness
(3) to facilitate further research into specific morbidities
It is important to note that PICS is not a medical diagnosis,
but a concept for improving education and awareness of
post-ICU impairments

6. Post-intensive care syndrome (PICS)
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
• Physical function
• Cognitive function
• Psychiatric function
Definition:

7. • (TBI) or (CVA), have been excluded
• the psychological health of family members of the survivor may
also be affected in an adverse manner as response to the stress of
critical illness in a loved one, termed as PICS-Family (PICS-F)
• there is no set duration of time after a critical illness where PICS
can or cannot occur

8. Epidemiology
The epidemiology of (PICS) is poorly studied.
Physical impairment is present in 25-80% of adult ICU survivors (sepsis)
possibly due to the involvement of inflammatory cytokines in the
pathogenesis of ICUAW.
Cognitive dysfunction occurs in up to 80% of adult ICU survivors, and while
this generally improves over time, these changes may persist for years, (ARDS
or sepsis).
(PTSD) have been reported in up to 50% of adult ICU survivors, and persist
for years following hospital discharge.

9. Risk factors
cognitive impairment risk factors
• acute brain dysfunction (eg, alcoholism, stroke),
• hypoxemia (eg, ARDS, cardiac arrest),
• hypotension (eg, sepsis, trauma), glucose dysregulation,
• respiratory failure (eg, prolonged MV, COPD),
• ARDS. COVID-19 patients 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

10. Risk factors for psychiatric disease
Pre-existing anxiety, depression, and PTSD, as well as female sex, tall stature in
males, age <50 years, lower education level, pre-existing
disability/unemployment, premorbid alcohol abuse, ICU sedative ,analgesia
use and hypoglycemia and hypoxia
Glucocorticoids are associated with a reduced risk for PTSD
Risk factors for Physical – ICUAW
sepsis, multi-system organ failure. ARDS, systemic inflammatory response
syndrome, glucose dysregulation, older age, hyperoxia, and use corticosteroids.
The association between NMB and neuromuscular weakness one systematic
review suggests the relationship may exist among patients with sepsis

11. • Unloading respiratory musculature
• Skeletal muscle atrophy from disuse, inflammatory mediators, electrolyte
imbalances, endocrine dysfunction, and poor nutritional status
• Vitamin D deficiency, which is quite common in the general population
• Microvascular ischemia, also likely underlies the neuropathic components of
ICUAW

12. • Although muscle weakness may resolve after several weeks to
months, in numerous cases, the impairment of motor function
persists for months to years.
• Critically ill COVID-19 survivors are treated with steroids.
side effects,
immune dysfunction, dysglycemia, frail skin,
osteoporosis, sarcopenia, loss of muscle mass,
nervousness, and changes in mood

13. Risk factors for PICS-F include
poor communication between staff,
being in a decision-making role,
• ( female gender, younger age, lower educational level, and previous history of
mental health disorders)
• There is conflicting evidence regarding whether family involvement in medical
decision-making is protective or predictive of subsequent PICS-f,
• For example, a French study and Conversely, a US study
• cultural factors may explain differences across studies.

14. Pathophysiology
Physical impairement
• Prolonged immobilization and inflammatory cytokines
activate the ubiquitin-proteasome system, autophagy-
lysosome system, cause increased levels of proteolysis and
catabolism, manifesting clinically as the sarcopenia and
myopathy characteristic of ICUAW
• neuropathy, microvascular ischemia
(impairs neuronal mitochondrial function and causes
demyelination).

15. Putative mechanisms of intensive care unit‐acquired weakness

16. Cognitive impairment
unknown and might be a manifestation of brain dysfunction
The pathophysiologic mechanisms may include
• microglial activation,
• oxidative stress
• mitochondrial dysfunction
• and activation of apoptotic pathways Neuroinflammation as
higher levels of IL-6 and IL-10 have been associated with
decreased cognitive performance up to 4 years post-ICU
discharge.

17. Clinical picture and
manifestations
17
The symptoms start after the critical illness, persist after
discharge from the ICU and can last for weeks, months and
even years

18. 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.
problems in memory, attention, speed of mental processing,
speaking and executive (organization, design, and problem-
solving)
• Memory and executive function are most affected domains.
18

20. Psychiatric impairment
• 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.
• PTSD include affective and behavioral responses to stimuli that
provoke flashbacks, hyperarousal, and severe anxiety
• Sexual dysfunction is common particularly in those with symptoms
of PTSD
• Survivors of critical illness may have increased risk of suicide and
self-harm..
20

21. Physical impairment
ICUAW may include difficulty in ventilator weaning, impairments
in speaking or swallowing, and generalized weakness of the limbs.
further subdivided into
muscle deconditioning, (CIP), (CIM) and (CINM)
ranges from generalized poor mobility and multiple falls to
quadriparesis.
takes more than a year to recover fully.
ICUAW makes the activities of daily living difficult, including
grooming, dressing, feeding, bathing and walking.
21

22. Joint contractures develop as a complication of prolonged immobility.
the elbow and ankle, followed by the hip and knee
ectopic ossifications may actually further worsen motor function and HRQOL
Reduced lung function.
The most common deficit is a reduction in diffusing capacity ,
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
O2 RARELY REQUIRED.
22

23. Symptoms of PICS-F in caregivers may include
sleep deprivation
Anxiety and/or depression
Feeling overwhelmed
Stress
Post-traumatic stress disorder
Grief
• Symptoms of PICS-F appear to last for months to years. Following discharge
of the loved one from the ICU
23

24. Evaluation
• specific post-ICU clinics are relatively common in the UK’s
National Healthcare System,
• Vanderbilt University established a post-ICU clinic, termed the
ICU Recovery Center, in 2012 to identify and treat PICS.
• The first visit 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.

25. Intensive Care Unit Clinics

26. ICU Follow-up Clinics
• staffed by pulmonary and critical care specialists coordination
between physical and occupational therapists, physical medicine
and rehabilitation physicians, neurologists, and neuropsychologists
• With regard to PICS-F, provide education and resources to families
experiencing PICS-F.
• The COVID-19 pandemic response telephone and teleconferencing
families to their loved ones may be of benefit

27. • Questionnaires to aid in the detection of PICS in the outpatient
setting.
they can be administered remotely as transportation to outpatient
clinics is often a problem for recovering ICU patients
• Telemedicine to evaluate patients for symptoms of PICS remotely.
• Other aspects of evaluation require inpatient visits, for example,
electromyography and nerve conduction studies can help to
distinguish myopathy and neuropathy from generalized weakness,

28. Cognition
screening tests usually performed for patients with suspected PICS include:
●Montreal Cognitive Assessment (MoCA
●Modified Mini-Mental State examination (MMSE)
●Mini-Cog
MoCA score <26 indicates mild cognitive impairment and a score <18 indicates
moderate to severe cognitive impairment consistent with dementia..
Mental health
A number of validated screening tests can be used to identify symptoms consistent
with depression, anxiety, or (PTSD)

29. Physical impairment
• by PT/OT 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
• electromyography and nerve conduction studies
• 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
• pulmonary function tests (spirometry, lung volumes, and diffusing capacity)
All mobile patients reporting symptoms should also undergo exercise
tolerance with a six-minute walk test.
29

30. Differential Diagnosis
.
The physical impairments
• weakness or neurological deficit, including stroke or disorders of
the spine. rhabdomyolysis, cachectic myopathy, and Guillain-Barré
syndrome may be confused with ICU-acquired weakness.
• distinguished from one another by laboratory and electrodiagnostic
findings and occasionally by muscle biopsy.
• Electrolyte, endocrine, or nutritional deficiencies

31. cognitive
pre-existing illnesses include prior cognitive deficits from developmental
defects
anxiety or panic disorder, depression or schizoaffective disorder, substance
abuse
dementia or traumatic brain injury
the course of different forms of dementia typically progressive, but of PICS
tend to be more stable over time.
memory deficits are usually less pronounced in PICS than in other dementia
syndromes,
while attention and processing speed are more significantly impacted. 31

32. 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.
32

33. Organic causes of symptoms that mimic
PICS
hypothyroidism, hyperthyroidism,
vitamin B12 deficiency, anemia, cancer,
obvious on routine laboratory testing or imaging
obtained during the ICU stay , history and clinical
examination

34. post-hospital syndrome
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
34

35. Management
Prevention and
treatment

36. • The most effective strategy to prevent PICS is to prevent critical
illness.
(eg, masking) and vaccination reduce (SARS-CoV-2
• In patients with moderate to severe acute hypoxemic respiratory
failure, the use of high-flow oxygen therapy reduces the need for
invasive mechanical ventilation and the inherent harms associated
with its use
Prevention

37. Once critical illness has developed,
• minimizes sedation
• early physical rehabilitation during (ICU) stay and
continuing through the recovery process.
• cognitive rehabilitation may prove to be of benefit in
conjunction with physical therapy
• A multidisciplinary team
(eg, primary care clinician, physical rehabilitation
clinician)
37

38. preventative measures that are initiated immediately in the ICU setting.
• The ABCDEF bundle
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

39. • preventing immobility and prolonged mechanical
ventilation
• for cognitive impairments by minimizing the exposure to
sedatives and preventing delirium
• Quality communication between the ICU team and family
members is also thought to decrease the risk of PICS-f.
• One well-studied method to address the mental health
aspects of PICS and PICS-f is the use of ICU diary

40. ICU Diaries

41. The ICU Diary
• 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.
• 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
• HRQOL also improved.
• reduced the risk of PTSD in family members

42. Treatment
Physical rehabilitation
The term “early” as much as 1 week
sitting, standing, and ambulation, as well as passive exercises
including range-of-motion exercises
Nutrition
appropriate energy delivery and avoid overfeeding.
Adequate protein delivery

43. Improved sleep quality by using noise
reduction devices could reduce the
development of delirium in the ICU
Music therapy or noise-canceling
headphones reduced anxiety during ICU
stay

45. Therapy for PTSD
• Behavioral Therapy
yoga, and acupuncture are popular in Eastern cultures
• Technological Therapy
. 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.

46. • Pharmacological Therapy
antidepressant medication, (SSRIs)
Propranolol, a beta-adrenergic blocker, acts as a protective
measure against the onset of PTSD.
Prazosin, an alpha-1 adrenergic blocker
• Group Therapy
offers cognitive skills and training in a way that can also
facilitate personal connection with others
46

47. Prognosis
• The long-term prognosis of (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 aid of PT/OT
• the cognitive and mental health problems may be more persistent.
• Cognitive deficits have been reported in 25% of ARDS survivors six years
post-discharge,
Patients with a higher illness severity discharged to a skilled care facility, and
those with an oncology diagnosis were at increased risk of early
rehospitalization.

48. • The risk of death remains elevated in patients after critical illness, particularly in
the first three to six months after an ICU admission
• multifactorial and related to pre-existing illnesses, new impairments, and/or a
decline in pre-existing organ dysfunction and impairments (PICS), that
predispose to acute illness.
• greatest risk of death after ICU discharge include
●Patients from medical ICUs (as opposed to surgical ICUs)
● sepsis
● malignancy
● ARDS
● neuromuscular weakness
● renal failure

49. 49

50. Incidence of post-ICU impairments
• a recent study of 2,345 ICU survivors in the Netherlands, collected
baseline health status via questionnaires completed by patients or
their proxies
• Among those admitted to the ICU for medical (N = 649, 28%),
urgent surgery (284, 12%), and elective surgery (1412, 60%), 58%,
64%, 43%, respectively, experienced new physical, cognitive and/or
mental problems
• The incidence of frailty, fatigue, muscle weakness, anxiety,
depression, and cognitive impairment at 1 year post-ICU was more
common among urgent surgical patients compared to elective ones
50

51. 51

52. • elective surgery tended to have a shorter ICU length
of stay than urgent surgery or medical patients
• Additionally, elective surgery patients were more
likely to demonstrate improvements in physical and
mental functioning at 1 year follow up
52

53. Subtypes of physical, cognitive and mental
health outcomes
• (
1
) mildly impaired physical and mental health status (22%)
• (2) moderately impaired physical and mental health status
(39%)
• (3) severely impaired physical and moderately impaired
mental health status (15%)
• (4) severely impaired physical and mental health status(24%)
53

54. Potential mechanisms
inflammatory subphenotypes
• Recent research, has explored the relationship between ICU-based
hyper- vs. hypo-inflammatory subphenotypes with physical,
cognitive and mental health impairments over 12-month follow-up
• The hyper-inflammatory phenotype was associated with decreased
survival within 90 days However, survival did not differ beyond 90
days based on inflammatory phenotype .
54

55. Additional aspects of PICS
•Fatigue
(female sex and unemployment prior to hospital admission
•Pain
Unemployment and the use of opioids in the ICU were associated with greater
pain at 6- and 12-month follow-up.
Among those with pain, 78% also reported anxiety and/or depressive symptoms
and 78% reported cognitive and/or physical function impairment.
patients with chronic pain may report higher pain after hospital discharge due to
opioid tolerance, hyperalgesia, or predisposition to developing a pain syndrome
55

56. 56
Barriers to return to work after critical illness
improve patient’s functional abilities, and to decrease work load
via workplace accommodations for ICU survivors

57. Take Home Messages
• PICS is common Can happen in families and survivors
• PICS is experienced by many ICU survivors who have new or worsening
physical, cognitive, and/or mental health impairments. These
impairments often co-occur and may include pain and fatigue
• Depression and anxiety predominate mental health problems and PTSD
can be as high as 1 in 4
• PICS-F. The psychological effects may persist for prolonged periods after
discharge of the loved one from theICU.
• We advocate for good communication strategies between staff and family
members of survivors of critical illness
• The signs and symptoms of PICS improve over the first 6 to 12 months following
discharge from the ICU. However, in many patients, deficits persist for years.

58. • PICS is frequently associated with the inability to return to work and
decreased quality of life as well as an increased risk of death over the
subsequent few years
• Increased understanding of risk factors, has improved our ability to
identify high-risk patients for screening and intervention
• Non-pharmacological interventions, including early mobilization and physical
rehabilitation in the ICU, ICU diaries, psychological interventions, multi-
disciplinary post-ICU follow-up clinics are still in an early stage.
• Future well-designed studies are needed to better understand mechanisms and
potential interventions to improve postintensive care syndrome.
PICS

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