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Introduction We examined the effectiveness of early rehabilitation for the prevention of postintensive care syndrome (PICS), characterised by an impaired physical, cognitive or mental health status, among survivors of critical illness.

Methods We performed a systematic literature search of several databases (Medline, Embase and Cochrane Central Register of Controlled Trials) and a manual search to identify randomised controlled trials (RCTs) comparing the effectiveness of early rehabilitation versus no early rehabilitation or standard care for the prevention of PICS. The primary outcomes were short-term physical-related, cognitive-related and mental health-related outcomes assessed during hospitalisation. The secondary outcomes were the standardised, long-term health-related quality of life scores (EuroQol 5 Dimension (EQ5D) and the Medical Outcomes Study 36-Item Short Form Health Survey Physical Function Scale (SF-36 PF)). We used the Grading of Recommendations Assessment, Development and Evaluation approach to rate the quality of evidence (QoE).

Results Six RCTs selected from 5105 screened abstracts were included. Early rehabilitation significantly improved short-term physical-related outcomes, as indicated by an increased Medical Research Council scale score (standardised mean difference (SMD): 0.38, 95% CI 0.10 to 0.66, p=0.009) (QoE: low) and a decreased incidence of intensive care unit-acquired weakness (OR 0.42, 95% CI 0.22 to 0.82, p=0.01, QoE: low), compared with standard care or no early rehabilitation. However, the two groups did not differ in terms of cognitive-related delirium-free days (SMD: −0.02, 95% CI −0.23 to 0.20, QoE: low) and the mental health-related Hospital Anxiety and Depression Scale score (OR: 0.79, 95% CI 0.29 to 2.12, QoE: low). Early rehabilitation did not improve the long-term outcomes of PICS as characterised by EQ5D and SF-36 PF.

Conclusions Early rehabilitation improved only short-term physical-related outcomes in patients with critical illness. Additional large RCTs are needed.

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This booklet deals with some common problems that people may
experience when they leave intensive care. However, everyone is
different and you might find you do not experience any of these
problems at all. If you do, we have tried to offer some ways of
dealing with them, which we hope will be helpful to you and
your family.

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A substantial number of patients admitted to the ICU because of an acute illness, complicated surgery, severe trauma, or burn injury will develop a de novo form of muscle weakness during the ICU stay that is referred to as “intensive care unit acquired weakness” (ICUAW). This ICUAW evoked by critical illness can be due to axonal neuropathy, primary myopathy, or both. Underlying pathophysiological mechanisms comprise microvascular, electrical, metabolic, and bioenergetic alterations, interacting in a complex way and culminating in loss of muscle strength and/or muscle atrophy. ICUAW is typically symmetrical and affects predominantly proximal limb muscles and respiratory muscles, whereas facial and ocular muscles are often spared. The main risk factors for ICUAW include high severity of illness upon admission, sepsis, multiple organ failure, prolonged immobilization, and hyperglycemia, and also older patients have a higher risk. The role of corticosteroids and neuromuscular blocking agents remains unclear. ICUAW is diagnosed in awake and cooperative patients by bedside manual testing of muscle strength and the severity is scored by the Medical Research Council sum score. In cases of atypical clinical presentation or evolution, additional electrophysiological testing may be required for differential diagnosis. The cornerstones of prevention are aggressive treatment of sepsis, early mobilization, preventing hyperglycemia with insulin, and avoiding the use parenteral nutrition during the first week of critical illness. Weak patients clearly have worse acute outcomes and consume more healthcare resources. Recovery usually occurs within weeks or months, although it may be incomplete with weakness persisting up to 2 years after ICU discharge. Prognosis appears compromised when the cause of ICUAW involves critical illness polyneuropathy, whereas isolated critical illness myopathy may have a better prognosis. In addition, ICUAW has shown to contribute to the risk of 1-year mortality. Future research should focus on new preventive and/or therapeutic strategies for this detrimental complication of critical illness and on clarifying how ICUAW contributes to poor longer-term prognosis.

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Surgical intensive care unit (ICU) stay of longer than 10 days is often described by the experienced intensivist as a ‘‘complicated clinical course’’ and is frequently attributed to persistent immune dysfunction. ‘‘Systemic inflammatory response syndrome’’ (SIRS) followed by‘‘compensatory anti-inflammatory response syndrome’’ (CARS) is a conceptual framework to explain the immunologic trajectory that ICU patients with severe sepsis, trauma, or emergency surgery for abdominal infection often traverse, but the causes, mechanisms, and reasons for persistent immune dysfunction remain unexplained. Often involving multiple-organ failure (MOF) and death, improvements in surgical intensive care have altered its incidence, phenotype, and frequency and have increased the number of patients who survive initial sepsis or surgical events and progress to a persistent inflammation, immunosuppression, and catabolism syndrome (PICS). Often observed, but rarely reversible, these patients may survive to transfer to a long-term care facility only to return to the ICU, but rarely to self-sufficiency. We propose that PICS is the dominant patho physiology and phenotype that has replaced late MOF and prolongs surgical ICU stay, usually with poor outcome. This review details the evolving epidemiology of MOF, the clinical presentation of PICS, and our understanding of how persistent inflammation and immunosuppression define the pathobiology of prolonged intensive care. Therapy forPICS will involve innovative interventions for immune system rebalance and nutritional support to regain physical function and well-being. (J Trauma Acute Care Surg. 2012;72: 1491Y1501. Copyright*2012 by Lippincott Williams & Wilkins)

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Having a spouse in a hospital’s intensive care unit (ICU) may make a person more likely to have a heart attack or cardiac-related hospitalization themselves within a few weeks of the ICU admission, according to new research published today in the American Heart Association’s flagship journal Circulation.

“Spouses of ICU patients should pay attention to their own physical health, especially in terms of cardiovascular disease,” said the study’s senior author Hiroyuki Ohbe, M.D., M.P.H., a Ph.D. student in the department of clinical epidemiology and health economics in the School of Public Health at The University of Tokyo in Japan. “The ICU can be a stressful environment with significant caregiving burdens, and spouses may face tough decisions about continuing or ending life-sustaining treatment.”

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Aim
To describe published literature on the needs and experiences of family members of adults admitted to intensive care and interventions to improve family satisfaction and psychological well‐being and health.
Design
Scoping review.
Methods
Several selective databases were searched. English‐language articles were retrieved, and data extracted on study design, sample size, sample characteristics and outcomes measured.
Results
From 469 references, 43 studies were identified for inclusion. Four key themes were identified: (a) Different perspectives on meeting family needs; (b) Family satisfaction with care in intensive care; (c) Factors having an impact on family health and well‐being and their capacity to cope; and (d) Psychosocial interventions. Unmet informational and assurance needs have an impact on family satisfaction and mental health. Structured written and oral information shows some effect in improving satisfaction and reducing psychological burden. Future research might include family in the design of interventions, provide details of the implementation process and have clearly identified outcomes.

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Rationale: Post–intensive care syndrome (PICS), defined as new or worsening impairment in cognition, mental health, or physical function after critical illness, is an important development in survivors. Although studies to date have focused on the frequency of these impairments, fundamental questions remain unanswered regarding the survivor experience and the impact of the critical illness event on survivor resilience and recovery.

Objectives: To examine the association between resilience and neuropsychological and physical function and to contextualize these findings within the survivors’ recovery experience.

Methods: We conducted a mixed-methods pilot investigation of resilience among 43 survivors from two medical intensive care units (ICUs) within an academic health-care system. We interviewed survivors to identify barriers to and facilitators of recovery in the ICU, on the medical ward, and at home, using qualitative methods. We used a telephone battery of standardized tests to examine resilience, neuropsychological and physical function, and quality of life. We examined PICS in two ways. First, we identified how frequently survivors were impaired in one or more domains 6–12 months postdischarge. Second, we identified how frequently survivors reported that neuropsychological or physical function was worse.

Measurements and Main Results: Resilience was low in 28% of survivors, normal in 63% of survivors, and high in 9% of survivors. Resilience was inversely correlated with self-reported executive dysfunction, symptoms of anxiety, depression, and post–traumatic stress disorder, difficulty with self-care, and pain (P < 0.05). PICS was present in 36 survivors (83.7%; 95% confidence interval, 69.3–93.2%), whereas 23 survivors (53.5%; 95% confidence interval, 37.6–68.8%) reported worsening of neuropsychological or physical function after critical illness. We identified challenges along the recovery path of ICU survivors, finding that physical limitations and functional dependence were the most frequent challenges experienced in the ICU, medical ward, and on return to home. Spiritual and family support facilitated recovery.

Conclusions: Resilience was inversely correlated with neuropsychological impairment, pain, and difficulty with self-care. PICS was present in most survivors of critical illness, and 54% reported neuropsychological or physical function to be worse, yet resilience was normal or high in most survivors. Survivors experienced many challenges during recovery, while spiritual and family support facilitated recovery.

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Survivors of critical illness often experience new or worsening impairments of physical, cognitive, and/or mental health, referred to as Post-Intensive Care Syndrome (PICS). Such impairments can be long-lasting and negatively affect survivors’ quality of life. Early rehabilitation in the intensive care unit (ICU), while patients remain on life-support therapy, may reduce the complications associated with PICS. This article addresses evidence-based rehabilitation interventions to reduce the physical and mental health impairments associated with PICS. Implementation of effective early rehabilitation interventions targeting physical impairment requires consideration of five factors: barriers, benefits, feasibility, safety, and resources. Mental health impairments may be addressed by use of the following interventions: use of ICU diaries, early in-ICU psychological interventions, and post-ICU coping skills training. In both cases, a multidisciplinary team-based approach is paramount to successful incorporation of early rehabilitation into routine practice in the ICU.

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Background: Admission of a patient in the Intensive Care Unit (ICU) and the recovery process may be stressful for family members.
Objectives: This study aimed to explore the families' psychological symptoms and their evolution over the 1st week of patients' ICU stay. Additional objectives were the estimation of the families' need for support and the estimation of satisfaction regarding the information provided by ICU physicians.
Methods: A total of 108 individuals were participated in the study. Participants were interviewed with the Hamilton Anxiety Rating Scale and filled the Beck Depression Scale II on days 1 and 7 of patients' ICU admission. They also filled a self-reported questionnaire which was created by the investigators, involving decision-making procedures; the satisfaction of the families of the patients' care; and the support of the families by medical and nursing staff.
Results: Anxiety levels were not significantly different among 2-time points, whereas rates of depressive symptoms raised significantly from 38% (day 1) to 58.3% (day 7). In cases of anxiety changes, age, education, closeness of relationship, and APACHE II score were the factors been associated. Changes in depressive symptoms were not associated with any of those factors. Over a week, there were significant differences in relatives' views on participating in the decision-making procedure, and on expressing their opinion and concerns regarding the treatment process. Their attitudes about receiving support by the ICU personnel and even by mental health specialists, such as psychologists also changed.
Conclusions: Over the 1st week of ICU admission, depressive symptoms in patients' relatives were gradually evolving, while anxiety symptoms fluctuated and they were affected by the severity of the patients' condition. Attitudes toward treatment procedures and the perceived need for support also changed. These findings should be taken into account by the ICU personnel.

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Course Description:
5 million people enter ICUs in the USA each year and over 80% of survivors of critical illness experience post-intensive care syndrome (PICS) – a constellation of cognitive, psychological, and physical symptoms including prolonged muscle weakness, reduced performance of activities of daily living, diminished ambulation and strength, post
traumatic stress disorder, and anxiety. These symptoms persist for months and years following hospital discharge. This session will examine the etiology of symptoms comprising PICS and discuss evidence-based tests and measures to objectively examine individuals with PICS. Outcomes from recent clinical trials of interventions for people with PICS will be analyzed and sample intervention programs will be described. This course will conclude with an exploration of challenges associated with the transitions of care experienced by individuals with PICS and offer some solutions.

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PICS/PICS-F overview for caregivers.

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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 postintensive care syndrome (PICS) and in families as postintensive care syndrome-family (PICS-F) (1).
The research findings are disturbing and a source of dis tress to critical care practitioners. In response, they are work ing 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 patients post-ICU to identify and treat the consequences of critical illness in patients and families.