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When patients enter the dynamic environment of an intensive care unit (ICU) they are often not only critically ill but are also experiencing a psychological crisis (Hardicre, 2003a). Last week two studies were published that highlight the stressful effects of this experience.

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Post-traumatic stress disorder (PTSD) may develop after exposure to a life-threatening event or serious injury. Symptoms include recurring and intrusive memories, such as flashbacks, avoidance of reminders and persistent symptoms of anxiety or physiological arousal. Many factors are associated with the development of PTSD in intensive care unit (ICU) patients, including increased length of stay, and greater levels and longer duration of sedation. Patient-related factors associated with a higher risk of PTSD include younger age, female gender, previous psychological problems and recall of delusional memories from ICU. In contrast, the formation of even fragmented factual memories may reduce the risk of PTSD.

Optimum, analgesia-based sedation may help patients to form factual memories of ICU, so possibly reducing the risk of PTSD. Patient diaries, written by health professionals and family members and close friends, may also support patients in coming to terms with traumatic, delusional memories, and so reduce their emotional and psychological symptoms. Following ICU discharge, validated screening tools such as ICU Memory and Post-traumatic Stress Syndrome 14-Questions Inventory can be used as part of routine follow-up to identify patients who may need referral for more specialist assessment of possible PTSD symptoms.

Brief description of media:

Post-traumatic stress disorder (PTSD) may develop after exposure to a life-threatening event or serious injury. Symptoms include recurring and intrusive memories, such as flashbacks, avoidance of reminders and persistent symptoms of anxiety or physiological arousal. Many factors are associated with the development of PTSD in intensive care unit (ICU) patients, including increased length of stay, and greater levels and longer duration of sedation. Patient-related factors associated with a higher risk of PTSD include younger age, female gender, previous psychological problems and recall of delusional memories from ICU.

In contrast, the formation of even fragmented factual memories may reduce the risk of PTSD. Optimum, analgesia-based sedation may help patients to form factual memories of ICU, so possibly reducing the risk of PTSD. Patient diaries, written by health professionals and family members and close friends, may also support patients in coming to terms with traumatic, delusional memories, and so reduce their emotional and psychological symptoms. Following ICU discharge, validated screening tools such as ICU Memory and Post-traumatic Stress Syndrome 14-Questions Inventory can be used as part of routine follow-up to identify patients who may need referral for more specialist assessment of possible PTSD symptoms.

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A stay in the intensive care unit (ICU) can be traumatic. Patients are confronted with their own mortality. They are rolled in and hooked up to machines. Perhaps they are ventilated or catheterised. They might drift in and out of consciousness, seeing a different set of faces each time they wake. Confusion, sedation, and delirium make it difficult to communicate; intubation makes it impossible. Mysterious alarms ring at strange times.

If the stay is long enough, there is likely to be a death, perhaps more than one, elsewhere in the ward. Hallucinations are common, some of which sound like a scene from a horror movie. “I have had patients talk about seeing blood dripping down the walls, or children with no faces”, said Joseph Bienvenu (Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA). Symptoms of post-traumatic stress disorder (PTSD) vary from person to person, but typically include a combination of flashbacks and nightmares, avoiding reminders of the traumatic event, emotional numbing, and hyperarousal. Symptoms generally develop within a month, but some patients experience delayed onset. Around 60% of patients recover naturally within 5 years.

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Expanding elderly populations are a major social challenge in advanced countries worldwide and have led to a rapid increase in the number of elderly patients in intensive care units (ICUs). Innovative advances in medical technology have enabled lifesaving of patients in ICUs, but there remain various problems to improve their long‐term prognoses.

Post‐intensive care syndrome (PICS) refers to physical, cognition, and mental impairments that occur during ICU stay, after ICU discharge or hospital discharge, as well as the long‐term prognosis of ICU patients. Its concept also applies to pediatric patients (PICS‐p) and the mental status of their family (PICS‐F). Intensive care unit‐acquired weakness, a syndrome characterized by acute symmetrical limb muscle weakness after ICU admission, belongs to physical impairments in three domains of PICS.

Prevention of PICS requires performance of the ABCDEFGH bundle, which incorporates the prevention of delirium, early rehabilitation, family intervention, and follow‐up from the time of ICU admission to the time of discharge. Diary, nutrition, nursing care, and environmental management for healing are also important in the prevention of PICS. This review outlines the pathophysiology, prevention, and future directions of PICS.

Brief description of media:

Expanding elderly populations are a major social challenge in advanced countries worldwide and have led to a rapid increase in the number of elderly patients in intensive care units (ICUs). Innovative advances in medical technology have enabled lifesaving of patients in ICUs, but there remain various problems to improve their long‐term prognoses. Post‐intensive care syndrome (PICS) refers to physical, cognition, and mental impairments that occur during ICU stay, after ICU discharge or hospital discharge, as well as the long‐term prognosis of ICU patients. Its concept also applies to pediatric patients (PICS‐p) and the mental status of their family (PICS‐F).

Intensive care unit‐acquired weakness, a syndrome characterized by acute symmetrical limb muscle weakness after ICU admission, belongs to physical impairments in three domains of PICS. Prevention of PICS requires performance of the ABCDEFGH bundle, which incorporates the prevention of delirium, early rehabilitation, family intervention, and follow‐up from the time of ICU admission to the time of discharge. Diary, nutrition, nursing care, and environmental management for healing are also important in the prevention of PICS. This review outlines the pathophysiology, prevention, and future directions of PICS.

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Posthospital care of ICU survivors remains both a challenge and an opportunity. The mandate to optimize critical illness recovery with tailored survivorship programs seems clear. Additional research and clinical experience are needed to further delineate the needs of ICU survivors and develop effective interventions to mitigate the effects of PICS, with the goal of maximizing recovery after critical illness.

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Advances in critical care medicine have led to improved outcomes; as a result, most patients will survive their critical illness episode. However, many survivors do not return to their pre critical illness functional levels. Rather, survivors of critical illness often experience impairments in cognition, mental health, and physical health that endure. Research over the past 2 decades has increased our knowledge and awareness of these morbidities after critical illness. Post–intensive care syndrome (PICS), a term coined in 2012 to raise awareness of these impairments, is common after critical illness. Specifically, 34% of patients who experience shock and/or require invasive mechanical ventilation experience cognitive impairment at 12 months at a level consistent with moderate traumatic brain injury.

Symptoms of anxiety, depression, and/or posttraumatic stress disorder (PTSD) afflict approximately 25% of survivors of critical illness, and 27% of survivors are physically impaired at 1 year after critical illness. Together, 56% of survivors experience a new, enduring impairment in 1 or more of these domains, and 21% experience 2 or more impairments at 1 year.

Similarly, findings from a small telephone-based study that used patient report of problems found that 54% of patients developed impairments and 56% of patients had 2 or more impairments after critical illness. Related to the 3 domains that define PICS—impairments in cognition, mental health, and physical health survivors experience a myriad of challenges and functional impairments, including pulmonary dysfunction, particularly among survivors of acute respiratory distress syndrome (ARDS); chronic pain; sexual dysfunction; and functional disability related to contractures. These impairments contribute to the reduced health-related quality of life that has been observed among survivors of critical illness as well as the inability to return to full-time employment.

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PICU Outcomes

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PostICU Glossary

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Since critical care began over 50 years ago, there have been tremendous advances in the science and practice that allow more severely ill and injured patients to survive. Each year, millions of people are discharged back to the community. The recognition of long-term consequences for ICU survivors and their families is a growing concern. Critical care practitioners have always known that the patients have a long road to recovery after discharge from the ICU. In the 2 past decades, research has revealed how remarkably common and devastating long-term consequences of critical illness can be and how much some patients and their families suffer (1–9). These consequences in patients are referred to as post intensive care syndrome (PICS) and in families as post intensive care syndrome-family (PICS-F) (1).

Brief description of media:

Since critical care began over 50 years ago, there have been tremendous advances in the science and practice that allow more severely ill and injured patients to survive. Each year, millions of people are discharged back to the community. The recognition of long-term consequences for ICU survivors and their families is a growing concern. Critical care practitioners have always known that the patients have a long road to recovery after discharge from the ICU. In the 2 past decades, research has revealed how remarkably common and devastating long-term consequences of critical illness can be and how much some patients and their families suffer (1–9).

These consequences in patients are referred to as post intensive care syndrome (PICS) and in families as post intensive care syndrome-family (PICS-F). The research findings are disturbing and a source of dis tress to critical care practitioners. In response, they are working hard to identify the risk factors for PICS and are rapidly implementing ways to mitigate their impact. Although the critical care community is becoming increasingly aware of PICS, patients, families, and the posthospital care community need more information. They are the ones who are deal most directly PICS and PICS-F.

There are three key emerging concepts driving these initiatives: a focus on safe transitions and handoffs, an emphasis on family-centered care, and the acceptance that critical care is defined by the whole episode of care, not just the ICU stay. It is clear that those in the field of critical care have a responsibility to increase the awareness and to work with those who care for patient’s post-ICU to identify and treat the consequences of critical illness in patients and families.