Preparing Patients for Life After the ICU

2013 - 4 August - Managing Post-Intensive Care Syndrome in the ICU
Promise Ariyo, MD; Sandy Swoboda, RN, MS, FCCM
Surviving critical illness is no small feat but with continued advances in medical care, millions of patients are discharged from intensive care units (ICUs) every year.(1)

 

Surviving critical illness is no small feat but with continued advances in medical care, millions of patients are discharged from intensive care units (ICUs) every year.(1) These patients often have a long road to recovery, and the medical community is becoming increasingly aware of the  challenges, effort, time and resources needed to return to a good functional status. Long-lasting impairments in mental health and cognitive and physical domains, termed post-intensive care syndrome (PICS), may occur after a critical illness and can last for months to years. Symptoms of anxiety, depression, post-traumatic stress disorder, profound neuromuscular weakness, and neuropsychiatric and cognitive deficits can impact the rehabilitation of ICU survivors.(2) Impaired swallowing and speech, trouble sleeping, nightmares and fatigue can interfere with the ability to perform routine daily activities. Additionally, these patients often have financial pressures, including lost wages, loss of employment and housing, diminished social interactions within and outside the family unit, and possibly a declaration of bankruptcy. The stress of the illness can disrupt the dynamics of the family and caregivers, with many experiencing changes in role function, social isolation, anxiety and depression, both during and after the critical care experience.(3) These issues can have a long-lasting impact, and critical care practitioners have a responsibility to prepare patients and their families for both the ICU experience and the potential challenges afterwards. Awareness, research and action are needed to provide adequate resources to help patients navigate a successful recovery.
 
Preparing for Long-Term Effects
 
Physiologic derangements, including hypotension, hypoxemia, inflammation, suboptimal nutrition and abnormalities in sleep-wake cycles, are all implicated in the pathophysiology of PICS. Sedation, immobility and mechanical ventilation, although necessary, can be detrimental to long-term functional outcomes. ICU-directed interventions aimed at addressing these issues are essential for improving patient outcomes. Concentrated efforts by clinicians to apply strategies, such as the ABCDE (Awakening and Breathing trial, Coordination, choice of sedatives and analgesics, Delirium monitoring and Early mobility) approach to patient care, are becoming routine standards of care.(4) The aim is to lessen sedation and begin early mobility. Daily awakening and delirium assessments, spontaneous breathing trials, use of sedatives with fewer side effects, and early mobility guide ICU patient care. These early rehabilitation efforts decrease delirium, reduce long-term cognitive effects and prevent physical weakness and deconditioning. 
 
Education and discussion with the patient and family during hospitalization are necessary to help identify potential problems early. Routine family meetings, social work consultation and counseling may prepare families for what lies ahead. Post-ICU planning should become a standard component of family meetings, especially as the patients near discharge. Information and an awareness of subtle signs of dysfunction (e.g., change in mood or attitude, fatigue, nightmares, delusions) should be highlighted to help the family anticipate, manage and navigate the recovery period. A team-based approach includes communication with family members, the primary care physicians, psychiatrists, physiatrists and rehabilitation facilities, so that all may help address the potential cognitive, emotional and physical sequelae that patients may face. 
 
After discharge, a multiprofessional team of specialists could offer support in the identification and management of some common PICS symptoms. Some countries have established follow-up clinics for routine post-ICU care, where symptoms and functional status can be assessed and resources employed as needed.(5) Educating families and primary healthcare providers about the ICU stay and possible related deficits is important to guide care and secure the resources needed to help the patient recover from the multifaceted problems that may follow discharge.(6) ​
 
References
  1. Wunsch H, Guerra C, Barnato AE, Angus DC, Li G, Linde-Zwirble WT. Three-year outcomes for Medicare beneficiaries who survive intensive care. JAMA. 2010;303(9):849–856.
  2. Desai SV, Law TJ, Needham DM. Long-term complications of critical care. Crit Care Med. 2011;39(2):371–379.
  3. Kentish-Barnes N, Lemiale V, Chaize M, Pochard F, Azoulay E. Assessing burden in families of critical care patients. Crit Care Med. 2009;37(10 Suppl):S448–S456.
  4. Wergin, R, Modrykamien A. Cognitive impairment in ICU survivors: assessment and therapy. Cleve Clin J Med. 2012;79(10):705-712.
  5. Griffiths, JA, Barber VS, Cuthbertson BH, Young JD. A national survey of intensive care follow-up clinics. Anaesthesia. 2006;61(10):950-955.
  6. Volk B, Grassi F. Treatment of the post-ICU patient in an outpatient setting. Am Fam Physician. 2009;79(6):459-464.