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Our project addresses one of the pressing issues of ICU medicine—the post-ICU patient. Research has documented deficits faced by survivors of intensive care, specifically neuro-cognitive dysfunction, depression, anxiety, and post-traumatic stress. These long-lasting disabilities present an important and prevalent public health concern. Although clinicians are increasingly aware of the challenges that face ICU survivors, they do not frequently discuss this with patients or families. As a result, patients often face a bewildering number of care transitions—from hospitals to long-term care to nursing facilities—without a roadmap or community. Furthermore, there is little research that investigates which outcomes are important to ICU survivors and their families, or how to change care with these outcomes in mind.

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Aggressive reimbursement reform has been an imposing directive for care providers of ICU medicine. Timely knowledge of actual care routines obtained from a large sample of actively practicing physicians should be mandatory when developing any guidelines or practice standards. A questionnaire was therefore designed by the steering committee of the ACCP Council on Critical Care and sent to its members. The 1,294 responses were analyzed for demographics of the individual practitioner, local aspects of ICU staffing and policies, reimbursement, and a specific practice issue, nutrition. The typical respondent was aged 41 to 50 (41 percent), was a pulmonary subspecialist (68 percent), was not critical care certified (55 percent), worked 25 to 50 percent of his or her total time in the ICU (40 percent), and would continue ICU practice despite poor reimbursement (82 percent). Physicians practiced within a group (53 percent), in a 100- to 500-bed hospital (69 percent), with house staff available (60 percent), and predominantly cared for Medicare patients (55 percent). The following data may allow better judgments to be made pertaining to the implementation of care policies in the current ICU environment.

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Another reason to be wary of a hospital stay- a new study shows that patients who survive intensive care units in hospitals are at high risk for developing post-traumatic stress disorder (PTSD).

PTSD is in the news most often in relation to combat veterans, but researchers from the Johns Hopkins University School of Medicine found that one in three people who survived an intensive care unit (ICU) stay for acute lung injury showed PTSD symptoms that lasted up to two years.

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Post Intensive Care Syndrome (PICS) is a group of health problems that can include physical impairments, mental health issues, and cognitive difficulties following a critical illness or hospital stay. Critical diseases can consist of but are not limited to heart attacks, stroke, congestive heart failure, pneumonia, pulmonary embolism, motor vehicle accident, burns, and surgical problems. Nearly one million people are admitted to the ICU each year, with close to a third requiring ventilation. Sepsis, delirium, and acute respiratory distress syndrome increase the odds of being diagnosed with PICS.

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Post-traumatic stress disorder (PTSD) can occur after someone experiences a traumatic event. The actual event can be short-lived, such as witnessing an accident or being a victim of a crime, or it can be long-term, like living in an abusive situation or being in a war zone. Not everyone who experiences such events develops PTSD and researchers don’t know why some people do while others don’t.

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To recap from our first post in this series, the definition of Post Intensive Care Syndrome (PICS) is new or worsening health problems after a stay in the ICU. These health problems can affect the body, mind, and/or emotions and often present after the patient has been discharged from the hospital. These problems may last anywhere from a few weeks, to months, and in some cases even years. People with PICS often experience a wide array of symptoms.

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Experiencing critical illness and intensive care can be extremely stressful. Roughly 1 in 5 critical illness
survivors have clinically significant post-traumatic stress disorder (PTSD) symptoms in the year after
intensive care, according to an article in press in the journal Critical Care Clinics.

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Improvements in devices and techniques used to provide life support for patients at intensive care units have reduced patient mortality. Increases in the number of survivors from a critical illness have brought long-term complications experienced during the post-intensive care period into question. The term post-intensive care syndrome (PICS) is defined as a new and deteriorating disorder in the cognitive, mental, and physical health status experienced by the survivor after intensive care unit discharge that might continue for months or even years. Opioid and sedation exposure, the severity of illnesses and injuries, dense life support interventions, length of stay in the intensive care unit,and social isolation constitute risk factors for PICS in children.These factors cause the child to experience deterioration in physical, cognitive, and psychological health domains. Such deteriorations occur on various levels and have negative effects on quality of life. The purpose of this article is to raise awareness and help pediatric nurses to develop an understanding of the condition. Increasing awareness by pediatric nurses about the magnitude and effects of complications after discharge from the intensive care unit will be the first step to protect survivors from new problems, to provide assistance for ongoing problems, and to develop follow-up strategies. PICS-related morbidities affect the majority of children discharged from PICUs. We need to understand the scope of those morbidities and develop efficient nursing interventions accordingly. It is time to expand our goal for critical and noncritical care from life-saving into improvement of functional health status and quality of life

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Delirium affects nearly 70% of older adults hospitalized in the intensive care unit (ICU), and many of those will be left with persistent cognitive impairment or dementia. There are no effective and scalable recovery models to remediate ICU-acquired cognitive impairment and its attendant elevated risk for dementia or Alzheimer disease (AD). The Improving Recovery and Outcomes Every Day after the ICU (IMPROVE) trial is an ongoing clinical trial which evaluates the efficacy of a combined physical exercise and cognitive training on cognitive function among ICU survivors 50 years and older who experienced delirium during an ICU stay. This article describes the study protocol for IMPROVE.
IMPROVE is a four-arm, randomized controlled trial. Subjects will be randomized to one of four arms: cognitive training and physical exercise; cognitive control and physical exercise; cognitive training and physical exercise control; and cognitive control and physical exercise control. Facilitators administer the physical exercise and exercise control interventions in individual and small group formats by using Internet-enabled videoconference. Cognitive training and control interventions are also facilitator led using Posit Science, Inc. online modules delivered in individual and small group format directly into the participants’ homes. Subjects complete cognitive assessment, mood questionnaires, physical performance batteries, and quality of life scales at baseline, 3, and 6 months. Blood samples will also be taken at baseline and 3 months to measure pro-inflammatory cytokines and acute-phase reactants; neurotrophic factors; and markers of glial dysfunction and astrocyte activation.
This study is the first clinical trial to examine the efficacy of combined physical and cognitive exercise on cognitive function in older ICU survivors with delirium. The results will provide information about potential synergistic effects of a combined intervention on a range of outcomes and mechanisms of action.

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When we talk about critical illness recovery, we often speak about physical debility, fatigue, anxiety, depression and even anger. But less often do we name another very common experience and emotion - grief. After all, you just survived a critical illness, why would you be grieving? Shouldn't you be thankful, happy even? That may how the outside world interprets your experience, but for your thankfulness and happiness during this time may be very elusive emotions.

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These slides help the medical student understand the types of PICS, what makes up PICS, the “burden of survivorship” and some novel interventions for the treatment of PICS.

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Despite reduced mortality and increasing survival rate of ICU treatment, a large group of patients surviving the ICU have a variety of complaints. Survivors of critical illness can undergo dramatic changes in their lives as a result of their experience, with many having some form of deficit in one or more domains of physical, psychological or cognitive functioning. There is still much to learn about the magnitude of the so-called Post ICU Syndrome (PICS) in patients surviving in the ICU.