Lane-Fall: After the ICU: post-intensive care syndrome

Clinical Pearls: Thanks to Jessica Buchner, MD

Definition: new or worsened health problems after critical illness that remain after the patient leaves the hospital. Can affect the patient and/or his family

Desai SV et al, Crit Care Med, 2011 

Triad:

1. Physical impairment: anorexia, decreased dexterity, low exercise tolerance, weakness (critical illness neuromyopathy, myopathy, neuropathy).
   • Causes: bedrest/disuse atrophy, hyperglycemia, neuromuscular blocker use, steroid use
2. Cognitive impairment: attention deficits, memory loss, executive function impairment
   • Causes: anxiety, pain, sedation, delirium, hypoxemia, hypoglycemia
3. Mental health problems: anhedonia, anxiety, depression, PTSD

*All lead to decreased quality of life

Desai SV et al, Crit Care Med, 2011 

Triggers:

• Patient-level: age, dementia, pre-ICU functional status, psychiatric history
• Disease-related: admitting diagnosis, anemia, endocrinopathies, hypoxemia, infection, inflammation
• ICU factors: immobility, invasive procedures, light, noise, sedation

Measuring outcomes:

• Cognitive impairment: delirium assessment (CAM-ICU, ICDSC), neurocognitive assessments (intelligence, memory, orientation, attention, executive function)
  • Hopkins RO et al.: Looked at cognitive function of 94 ARDS survivors. Intelligence and memory testing: all survivors fell below mean at discharge and starting recovering at 1 and 2 years.
• Physical functioning: 6-minute walk test, pulmonary function testing, activities of daily living, instrumental ADLs, grip strength
  • Aitken LM et al.: 195 ICU survivors, 145 completed 6-minute walk test at 26 weeks. 94 improved, 51 did not
• Mental health problems: measuring for depression, anxiety, PTSD.
  • Hospital anxiety and depression scale (HADS), Impact of event scale, Post-traumatic stress syndrome scale.
  • One multi-hospital study of 520 acute lung injury patients: 25% with depression, 40% with anxiety, 20% with PTSD. Symptoms continued for entire follow-up period of 24 months (no drop off in incidence)

Prevention:

• Early physical mobility
• Maintain cognitive stimulation
• Re-orientation
• Reassurance
• Prevent pain/agitation/delirium
• Mental health: ICU diaries, recreational therapy (music, pets), pharmacotherapy

Family experience after the ICU:

• Emotional toll, physical toll, financial burden, competing priorities
• Davydow DS et al.: Depression scores of spouses of ICU patients with severe sepsis increase after ICU stay and remain elevated.

Management strategies:

• In-patient Care: Nutritional counseling, speech therapy, physical therapy, counseling/psychotherapy, recreational therapy, occupational therapy
• ICU follow-up clinics: non-attendance and cancellation rates are high, outcomes are mixed, appropriate population is unclear, follow-up intervals are unclear
• Patients report somatic complaints: appetite loss, nail ridging, sexual dysfunction, hair loss
• Financial consequences: in a Norwegian study of 194 patients only 55% had returned to work 1 year post ICU.