Survival ≠ Recovery: A Narrative Review of Post-Intensive Care Syndrome

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. 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Eaton T.L. et al.Characteristics of post-ICU and post-COVID recovery clinics in 29 U.S. health systems.Crit Care Explor. 2022; 4e0658Crossref PubMed Google Scholar This review describes the clinical manifestations of PICS and its impact on patients, families, and health care systems. We also discuss the relationship between PICS and social determinants of health and outline a framework for the evaluation and management of PICS.Clinical QuestionA 56-year-old woman with a history of diabetes and obesity was admitted to the ICU for pneumonia. Her hospitalization was complicated by ARDS, shock, acute renal failure, and central line-associated bacteremia. She required mechanical ventilation for 7 days, vasopressors for 5 days, and continuous renal replacement therapy for 4 days. She was noted to have severe delirium and agitation while intubated and required deep sedation on multiple occasions. She also demonstrated weakness and impaired mobility and was discharged to a rehabilitation facility. Today, she is undergoing post-ICU follow-up 1 month after discharge. Her family endorses issues with her memory. She scores 14/30 on the Montreal Cognitive Assessment, consistent with moderate cognitive impairment.Which of the following conditions is most associated with developing long-term cognitive impairment?A: shock B: delirium C: acute renal failure D: bacteremia A 56-year-old woman with a history of diabetes and obesity was admitted to the ICU for pneumonia. Her hospitalization was complicated by ARDS, shock, acute renal failure, and central line-associated bacteremia. She required mechanical ventilation for 7 days, vasopressors for 5 days, and continuous renal replacement therapy for 4 days. She was noted to have severe delirium and agitation while intubated and required deep sedation on multiple occasions. She also demonstrated weakness and impaired mobility and was discharged to a rehabilitation facility. Today, she is undergoing post-ICU follow-up 1 month after discharge. Her family endorses issues with her memory. She scores 14/30 on the Montreal Cognitive Assessment, consistent with moderate cognitive impairment. Which of the following conditions is most associated with developing long-term cognitive impairment? A: shock B: delirium C: acute renal failure D: bacteremia PICS can include impairments in cognition, mental health, physical function, or a combination thereof after critical illness (Fig 1A). A complex relationship can exist among these domains, with deficits in one realm often influencing and coexisting with deficits in others.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,12Sukantarat K. Greer S. 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