A Multidisciplinary Approach to PICS

2016 - 6 December – Survive and Thrive
Ashish Khanna, MD, FCCP; Nicholas A. Peters, PharmD, BCPS, BCCCP; Dennis Kim, MD, FRCSC, FACS, FCCP
Three experts discuss a multidisciplinary approach to addressing PICS.

It’s 2:00 a.m. on a snowy Christmas Eve in a large tertiary-care academic intensive care unit (ICU). A team of critical care providers is busy resuscitating a man who has just been flown into the ICU by medical transport. He is hypotensive, on three vasopressors, and in multiorgan failure secondary to a perforated bowel. He is taken to the operating room for a lifesaving procedure. Once he comes back to the unit, his fight for life resumes. Over the next six weeks, he sees it all, from prolonged respiratory failure necessitating a tracheostomy, gut ileus needing nutritional support via parenteral nutrition, multiple rounds of dialysis and multiple trips to the interventional radiology suite to drain possible pockets of fluid deep in the pelvis. As he recovers (or appears to recover), he slips in and out of ICU delirium and receives a number of cocktails with the potential to effectively prevent him from “going crazy.” The story goes on and on and on…. Several months have passed. The snow has melted away, welcoming spring and early summer. I run into a familiar face in the hallway outside the ICU. It’s him—I’m so happy to see him back on his feet. The last time I met him was four months ago when I sent him to the rehabilitation facility. But something is not right. He appears anxious as he talks to me and does not want to go inside the ICU and meet the many nurses who took care of him while he struggled with life and death. His daughter tells me that he has “never been the same” since. He needs multiple pharmacologic sleep aids and has had multiple visits with his primary care physician. He wakes up in the middle of the night screaming and feels he has been restrained in his bed in the ICU. Outside of the vivid ICU nightmares, his functionality at work has been suboptimal. His muscle strength is still not appropriate. He needs help and is frustrated that he has lost his independent and active lifestyle of the past. Sound like a familiar story? Yes, ICU survivors often have many stories to tell.(1) Unfortunately though, ICU providers may not always be available to listen.

Advances in the provision of quality critical care have resulted in both improved outcomes and an increase in the number of patients who survive critical illness.

Growing recognition of the impact of ICU admission on long-term patient- and family-centered outcomes has resulted in a myriad of multidisciplinary healthcare and research initiatives targeted at increasing awareness, recognition and strategies for decreasing post-intensive care syndrome (PICS).

The Society of Critical Care Medicine (SCCM) defines PICS as “new or worsening impairments in physical, cognitive, or mental health status arising from critical illness and persisting beyond hospitalization.”(1) Although the prevalence and epidemiology of PICS is currently not well defined, the physical, cognitive and psychological consequences of PICS on quality of life and socioeconomic status are well documented. Furthermore, family members and loved ones of ICU survivors may also be adversely affected across several psychological and physical domains, a condition termed PICS – family (PICS-F).

In addition to increasing public awareness through the provision of information resources, enhanced professional awareness across healthcare disciplines and various phases of patient recovery are paramount for identifying potential barriers to practice and setting much-needed research agendas. To this end, enhanced dissemination of knowledge of PICS at all phases of training is necessary to ensure high-quality care not only while in the ICU but also after ICU and hospital discharge.(2)

Several initiatives and strategies have been proposed to decrease the development of PICS in patients and family members. The ICU Liberation ABCDEF Improvement Collaborative continues to promote the ABCDEF bundle. Some in the critical care community have started to discuss expanding the bundle to ABCDEFGH. G stands for good handoff communication and H stands for handout materials on PICS and PICS-F.(3) Early mobilization and creation of ICU diaries have been associated with improved outcomes and may decrease the prevalence of PICS.(4) Post-ICU clinics and post-discharge follow-up programs represent other potential methods for addressing PICS and allow for tracking of progress through the application of functional reconciliation checklists.(5)

Pharmacologic intervention for prevention of PICS is in the early stages but some potential strategies have been identified, including light sedation, prevention and treatment of delirium, adequate pain control, and prevention of hypo- and hyperglycemia. Benzodiazepine use is an independent risk factor for delirium and has been associated with deeper levels of sedation compared to other available agents.(6–8) Using light levels of sedation may improve memory of a patient’s ICU and hospital stay and help protect against PICS and cognitive dysfunction. Multiple studies have confirmed the link between ICU delirium and the risk of long-term cognitive dysfunction.(9,10) Stated simply, a longer duration of delirium increases the risk of severe impairment up to one year after ICU discharge.(11)

An emphasis on treatment and prevention of delirium may limit the development of short- and long-term cognitive dysfunction and subsequent PICS. Inadequate pain control has been linked to numerous complications, including agitation and delirium.(12) The 2013 Pain, Agitation, and Delirium Guidelines place an emphasis on analagosedation and routine monitoring of pain in all patients.(13) Glucose dysregulation has been linked to increased morbidity, mortality and critical illness polyneuropathy.(14–16) Maintaining normoglycemia may prevent acute brain dysfunction and long-term cognitive dysfunction through prevention of cerebral atrophy and neuron injury.(17)

Less is known about individual medications that could treat and/or prevent PICS. However, propranolol has been shown to prevent stressful memories and transmission of stress hormones linked to posttraumatic stress disorder (PTSD).(18) These effects are both immediate (the medication is taken immediately before a traumatic memory or event) and last longer than two years.(19,20) Propranolol can be used to prevent sympathetic arousal from stressful memories and prevent PTSD by removing the association from the brain and the memory.(21) Although there are medication-related strategies for prevention of PICS, nonpharmacologic measures continue to be first-line treatment because of the multifactorial nature of PICS.

Several questions remain unanswered and several avenues unexplored. Are we teaching our current in-training residents and fellows enough about this problem? Is the emphasis of critical care training so centered on saving lives in the ICU that we forget what happens to our patients when they try to get back to their real lives beyond the ICU? Is there a need to look beyond the closed bed spaces of critical care units and set up post-ICU clinics as a continuum of critical care services and a means by which the average ICU patient can reconnect with the intensivist? Is there a need to expand critical care training and teaching to long-term acute care facilities, rehabilitation units and clinics? Further research and interprofessional collaboration is needed to improve our current understanding of the development, prevention and treatment of PICS. In addition to enhanced public education initiatives, an improved professional awareness across healthcare disciplines and the entire spectrum of functional recovery through several combined multidisciplinary initiatives is required to ensure optimal outcomes in survivors of critical illness.

References: 
 
1. Brown DL. Fantastic delusions, futility and a family’s love. Anesthesiology. 2013 Oct;119(4):984-986.
2. Needham DM, 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 Feb;40(2):502-509.
3. Davidson JE, Harvey MA, Bemis-Dougherty A, Smith JM, Hopkins RO. Implementation of the Pain, Agitation, and Delirium Clinical Practice Guidelines and promoting patient mobility to prevent post-intensive care syndrome. Crit Care Med. 2013 Sep;41(9 Suppl 1):S136-S145.
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