Survival ≠ Recovery

Abstract

Surviving critical illness does not always equate to recovery, with its aftermath frequently complicated by post-intensive care syndrome (PICS). This syndrome consists of a collection of new or worsening impairments in the physical, psychological, or cognitive domains that develop after critical illness. In this review, we describe the clinical manifestations, evaluation, and management of PICS. We also examine the interplay between PICS and social determinants of health. Finally, we discuss how multidisciplinary PICS clinics can be used to care for patients who survive the ICU and potentially improve care within the ICU. Surviving critical illness does not always equate to recovery, with its aftermath frequently complicated by post-intensive care syndrome (PICS). This syndrome consists of a collection of new or worsening impairments in the physical, psychological, or cognitive domains that develop after critical illness. In this review, we describe the clinical manifestations, evaluation, and management of PICS. We also examine the interplay between PICS and social determinants of health. Finally, we discuss how multidisciplinary PICS clinics can be used to care for patients who survive the ICU and potentially improve care within the ICU. Key Points1.Post-intensive care syndrome (PICS) impacts up to 80% of patients who survive the ICU, resulting in physical, cognitive, and psychological impairments.2.Intensivists should attempt to minimize common modifiable risk factors for PICS developing. These include higher cumulative dose of sedative drugs, immobility, delirium, sleep disturbance, and hyperglycemia.3.The social and financial impact of PICS can be substantial; up to 50% of patients who survive the ICU rely on long-term family caregiving support, and up to 40% of previously employed patients who survive the ICU are unable to return to work 1 year after critical illness.4.Survivors of critical illness should have outpatient follow-up within 4 weeks of hospital discharge, with structured assessments for physical, cognitive, and psychological impairments. Referral to a multidisciplinary PICS clinic should be made if available. 1.Post-intensive care syndrome (PICS) impacts up to 80% of patients who survive the ICU, resulting in physical, cognitive, and psychological impairments.2.Intensivists should attempt to minimize common modifiable risk factors for PICS developing. These include higher cumulative dose of sedative drugs, immobility, delirium, sleep disturbance, and hyperglycemia.3.The social and financial impact of PICS can be substantial; up to 50% of patients who survive the ICU rely on long-term family caregiving support, and up to 40% of previously employed patients who survive the ICU are unable to return to work 1 year after critical illness.4.Survivors of critical illness should have outpatient follow-up within 4 weeks of hospital discharge, with structured assessments for physical, cognitive, and psychological impairments. Referral to a multidisciplinary PICS clinic should be made if available. ICU mortality has declined over time,1Zimmerman J.E. Kramer A.A. Knaus W.A. Changes in hospital mortality for United States intensive care unit admissions from 1988 to 2012.Crit Care. 2013; 17: R81Crossref PubMed Scopus (298) Google Scholar despite increasing age and illness severity in the patient population.2Lilly C.M. Swami S. Liu X. Riker R.R. Badawi O. Five-year trends of critical care practice and outcomes.Chest. 2017; 152: 723-735Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar In turn, a population of survivors with various long-term sequelae of critical illness had been growing steadily. Although research historically focused on short-term mortality, an increasing amount of data has emerged on the high morbidity associated with survivorship, demonstrating that survivorship does not always equate to recovery.3Cuthbertson B.H. Scott J. Strachan M. Kilonzo M. Vale L. Quality of life before and after intensive care.Anaesthesia. 2005; 60: 332-339Crossref PubMed Scopus (148) Google Scholar Post-intensive care syndrome (PICS) has been recognized for > 1 decade and is defined as new or worsening impairment of physical, psychological, or cognitive health, or a combination thereof, after critical illness.4van Beusekom I. Bakhshi-Raiez F. de Keizer N.F. Dongelmans D.A. van der Schaaf M. Reported burden on informal caregivers of ICU survivors: a literature review.Crit Care. 2016; 20: 16Crossref PubMed Scopus (144) Google Scholar, 5Hauschildt K.E. Seigworth C. Kamphuis L.A. et al.Financial toxicity after acute respiratory distress syndrome: a national qualitative cohort study∗.Crit Care Med. 2020; 48: 1103-1110Crossref PubMed Scopus (0) Google Scholar, 6Bagshaw S.M. Stelfox H.T. Johnson J.A. et al.Long-term association between frailty and health-related quality of life among survivors of critical illness: a prospective multicenter cohort study.Crit Care Med. 2015; 43: 973-982Crossref PubMed Scopus (159) Google Scholar At the time of hospital discharge, up to 80% of patients who survive the ICU will have PICS symptoms, and although PICS can improve with time, more than one-half of patients will continue to experience symptoms at 1 year.7Needham D.M. Davidson J. Cohen H. et al.Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference.Crit Care Med. 2012; 40: 502-509Crossref PubMed Scopus (1403) Google Scholar, 8Marra A. Pandharipande P.P. Girard T.D. et al.Co-occurrence of post-intensive care syndrome problems among 406 survivors of critical illness.Crit Care Med. 2018; 46: 1393-1401Crossref PubMed Scopus (208) Google Scholar, 9Nanwani-Nanwani K. Lopez-Perez L. Gimenez-Esparza C. et al.Prevalence of post-intensive care syndrome in mechanically ventilated patients with COVID-19.Sci Rep. 2022; PubMed Scopus Google Scholar, Davidson J.E. care syndrome: and Care Med. 2016; PubMed Scopus Google Scholar has to the and for care has et of and clinics in Care 2022; PubMed Google Scholar This the clinical of PICS and its impact on and care We also discuss the between PICS and social determinants of and a for the and management of with a of and to the ICU for complicated by acute and for for and for 4 to have and and on also and and to a is follow-up 1 after family with on the with cognitive of the is associated with long-term cognitive acute with a of and to the ICU for complicated by acute and for for and for 4 to have and and on also and and to a is follow-up 1 after family with on the with cognitive of the is associated with long-term cognitive acute PICS can include impairments in health, or a combination after critical illness can among with in and with in A. Pandharipande P.P. Girard T.D. et al.Co-occurrence of post-intensive care syndrome problems among 406 survivors of critical illness.Crit Care Med. 2018; 46: 1393-1401Crossref PubMed Scopus (208) Google K. S. S. and psychological sequelae of critical PubMed Scopus Google D.M. of critical Care Med. PubMed Scopus Google Scholar clinical manifestations, and risk factors for impairment in are of critical illness are to cognitive of and P.P. Girard T.D. cognitive impairment after critical Med. Google D.M. cognitive impairment and among survivors of PubMed Scopus Google Scholar be with of patients who survive the ICU 1 year after and the of impairment in and A. A.A. outcomes after critical Care. 2018; PubMed Scopus Google Scholar can include a in or of can from in the of to of and return to Pandharipande P.P. Girard T.D. et and in survivors of critical illness in the a cohort Med. 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