ICU · Rehabilitation
Post-intensive care syndrome (PICS)
Also known as Post-intensive care syndrome (PICS) · ICU-acquired weakness · Post-ICU cognitive impairment · Post-ICU psychological morbidity · ICU follow-up clinics · Post-intensive care syndrome-family (PICS-F) · ICU recovery clinic · ICU diary
PICS describes new or worsening impairments in physical, cognitive, or mental health status persisting beyond hospital discharge after critical illness and ICU stay. Each domain is common: PTSD symptoms in about one in five survivors, depressive symptoms in about one in five, anxiety symptoms in about one in three, and cognitive impairment in about a third at one year. Physical: ICU-acquired weakness (CIM/CIP), fatigue, dyspnoea. Cognitive: impaired memory, executive dysfunction, attention deficits (resembles moderate TBI or mild Alzheimer disease). Mental health: PTSD, depression, anxiety. Risk factors: delirium duration (strongest cognitive predictor), sedation, immobility, sepsis, older age, pre-existing impairment. Prevention: minimise sedation (ABCDEF bundle), early mobilisation, delirium prevention, family engagement. Follow-up: ICU recovery clinics screening all three domains. Family members also affected (PICS-Family).
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- PICS is common, not rare — PTSD symptoms ~1 in 5, depression ~1 in 5, anxiety ~1 in 3, cognitive impairment ~1 in 3 at 1 year
- Delirium duration is the strongest predictor of long-term cognitive impairment
- Family members of ICU patients also develop PICS-F — PTSD symptoms in about a third of relatives at 90 days
- ICU-acquired weakness persists in 46-80% of ARDS survivors at 1 year and ~20% at 5 years
- Only about 60% of previously employed survivors return to work by 12 months — survival is not the same as recovery
- Cognitive impairment at 1 year (about a third) resembles moderate TBI or mild Alzheimer disease — even in young patients
Meet the patient
Margaret is 58 and was, until ten weeks ago, independent — office job, no comorbidity. She came in with community-acquired pneumonia and septic shock: vasopressors, 9 days ventilated, continuous renal replacement therapy, 6 days of delirium. Today, at the recovery clinic, she cannot walk to the shops, forgets the conversation you had five minutes ago, is tearful and anxious, and has not been back to work. Her family, her GP, and the team that discharged her are all relieved she survived; Margaret is disabled. That gap — between survival and recovery — is the whole of post-intensive care syndrome. [1]
Hold the two questions this raises — what is wrong with her, and what should we have done in the bed to prevent it — and everything below slots into place. [1]
References20ShowHide
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- [3]Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness N Engl J Med, 2013.PMID 24088092
- [4]Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial Lancet, 2009.PMID 19446324
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- [9]Herridge MS, Cheung AM, Tansey CM, et al. One-year outcomes in survivors of the acute respiratory distress syndrome N Engl J Med, 2003.PMID 12594312
- [10]Herridge MS, Tansey CM, Matté A, et al. Functional disability 5 years after acute respiratory distress syndrome N Engl J Med, 2011.PMID 21470008
- [11]Kamdar BB, Suri R, Suchyta MR, et al. Return to work after critical illness: a systematic review and meta-analysis Thorax, 2020.PMID 31704795
- [12]Fan E, Cheek F, Chlan L, et al. An official American Thoracic Society/International Society of Intensive Care Medicine Clinical Practice Guideline: the diagnosis of intensive care unit-acquired weakness in adults Am J Respir Crit Care Med, 2014.PMID 25496103
- [13]Stevens RD, Marshall SA, Cornblath DR, et al. A framework for diagnosing and classifying intensive care unit-acquired weakness Crit Care Med, 2009.PMID 20046114
- [14]Rousseau AF, Colson C, Minguet P, et al. Characteristics of Mid-Term Post-Intensive Care Syndrome in Patients Attending a Follow-Up Clinic: A Prospective Comparison Between COVID-19 and Non-COVID-19 ICU Survivors Crit Care Explor, 2023.PMID 36699242
- [15]Marra A, Ely EW, Pandharipande PP, Patel MB. The ABCDEF Bundle in Critical Care Crit Care Clin, 2017.PMID 28284292
- [16]Pun BT, Balas MC, Barnes-Daly MA, et al. Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults Crit Care Med, 2019.PMID 30339549
- [17]Nielsen AH, Angel S, Egerod I, et al. The effect of family-authored diaries on posttraumatic stress disorder in intensive care unit patients and their relatives: A randomised controlled trial (DRIP-study) Aust Crit Care, 2020.PMID 30795978
- [18]Herridge MS, Moss M, Hough CL, et al. Recovery and outcomes after the acute respiratory distress syndrome (ARDS) in patients and their family caregivers Intensive Care Med, 2016.PMID 27025938
- [19]Finfer S, Chittock DR, Su SY, et al. Intensive versus conventional glucose control in critically ill patients N Engl J Med, 2009.PMID 19318384
- [20]Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment J Am Geriatr Soc, 2005.PMID 15817019