post-intensive care syndrome (PICS)

Post-intensive care syndrome (PICS) primarily affects the patient following critical illness, encompassing new or worsening physical, cognitive, or mental health impairments that persist beyond acute hospital discharge (1,2).

However, the impact frequently extends to the patient's support network (1,2):

• PICS-F (family): psychological sequelae (anxiety, depression, PTSD, complicated grief) affecting relatives or caregivers of ICU patients
• PICS-p (paediatrics): applies to paediatric ICU survivors (primarily impacting the child) while incorporating an explicit social health domain for the family (schooling, family finances, and sibling distress) (3)

Clinical features

Impairments usually span one or more of three main domains (2,3)

• physical impairment:
  • ICU-acquired weakness (ICUAW), including critical illness myopathy (CIM), critical illness polyneuropathy (CIP), or critical illness neuromyopathy (CINM)
  • rapid diaphragmatic and respiratory muscle atrophy (often occurring within 48 hours of mechanical ventilation).
  • persistent fatigue, reduced exercise capacity, and difficulties with activities of daily living (ADLs)
• cognitive impairment:
  • memory deficits, executive dysfunction, reduced processing speed, and impaired attention
  • can persist for months to years post-discharge
  • strongly linked to the duration of ICU delirium, hypoxia, and glycemic variability during acute care
• mental health impairment:
  • post-traumatic stress disorder (PTSD), anxiety, and depression.
  • risk factors include prior psychiatric history, female sex, younger age, prolonged sedation, and delusional memories of the ICU

Prevention strategies (ABCDEF bundle)

In-hospital care pathways focus on reducing long-term sequelae (3):

• A: assess, prevent, and manage pain.
• B: both spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT).
• C: choice of analgesia and sedation (avoiding over-sedation and routine benzodiazepine use).
• D: delirium assessment, prevention, and management.
• E: early mobility and exercise.
• F: family engagement and empowerment (e.g. use of ICU diaries)

Primary care management

• screening and assessment:
  • evaluate cognitive function using validated tools (e.g. MoCA or MMSE) if cognitive decline is suspected
  • screen for mood disorders and PTSD using standard questionnaires (e.g. PHQ-9, GAD-7, PCL-5)
  • assess physical capability, ADL independence, and nutritional status
• medication review:
  • rationalise and de-prescribe temporary ICU medications that may have been inappropriately continued (e.g. proton pump inhibitors, antipsychotics, short-term sedatives)
• rehabilitation and referrals:
  • physical therapy and occupational therapy for mobility and functional recovery
  • community mental health or psychological support services (e.g. CBT for PTSD/anxiety)
  • post-ICU follow-up clinics where available locally
• caregiver support:
  • monitor family members for signs of caregiver burden, anxiety, or depression (PICS-F) and offer primary care or psychological support as required

Reference:

1. Needham DM, Davidson J, Hopkins RO, Weinert CR, Wunsch H, Pronovost PJ, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Crit Care Med. 2012 Feb;40(2):502-9.
2. Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: An overview. J Transl Int Med. 2017 Jun 30;5(2):90-2.
3. Inoue S, Nakanishi N, Amaya F, Fujinami Y, Hatakeyama J, Hifumi T, et al. Post-intensive care syndrome: Recent advances and future directions. Acute Med Surg. 2024 Apr 25;11(1):e929.