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Power point's objective: Define the characteristics of Post-Intensive Care Syndrome (PICS); Identify the incidence, prevalence and risk factors of PICS; and Identify strategies for preventing and managing PICS.

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For years it has been known that many patients who survive critical illness do not return to their original state of health, resulting in long-term consequences of critical illness. Weakness acquired in the intensive care unit (ICU) is a physical consequence occurring in 25% to 80% of patients who receive mechanical ventilation for more than 4 days and in 50% to 75% of patients with sepsis. Nearly all patients affected with ICU-acquired weakness have symptoms that persist years later. Issues with cognitive function occur in 30% to 80% of ICU survivors and include memory, planning, problem-solving, visual-spatial, and processing problems. Cognitive consequences may improve during the months after discharge. However, 25% of patients with adult respiratory distress syndrome (ARDS) have long-term persistent cognitive impairment 6 years after discharge. In several studies,1-3 survivors of severe sepsis who were more than 65 years of age still had cognitive impairment 8 years after hospital discharge. Anxiety, depression, and sleep disturbances can last from months to years. Survivors also experience post traumatic stress disorder (PTSD) long-term, with an incidence between 10% and 50% and persisting for up to 8 years. Follow-up studies longer than 8 years have not been reported, and for some survivors, these consequences of critical illness may not resolve.

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As many as 80% of ICU survivors have some form of cognitive or brain dysfunction, according to the Society of Critical Care Medicine. While receiving intensive care, patients often are heavily sedated and connected to a ventilator. During this time, a temporary brain injury can develop that is linked to later issues with memory and thinking. At the same time, many ICU survivors experience post-traumatic stress symptoms, including depression, prolonged muscle weakness, and fatigue.
Patients who survive sepsis are particularly vulnerable to post-ICU syndrome and about 1.4 million of them suffer from long-term disabilities, according to the Sepsis Alliance. The not-for-profit advocacy group is developing pamphlets on post-sepsis issues for patients, as well as spreading the word on social media websites

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The terms intensive care unit (ICU) syndrome and ICU psychosis have been used interchangeably to describe a cluster of psychiatric symptoms that are unique to the ICU environment. It is often postulated that aspects of the ICU, such as sleep deprivation and sensory overload or monotony, are causes of the syndrome. This article reviews the empirical support for these propositions. We conclude that ICU syndrome does not differ from delirium and that ICU syndrome is caused exclusively by organic stressors on the central nervous system. We argue further that the term ICU syndrome is dangerous because it impedes standardized communication and research and may reduce the vigilance necessary to promptly investigate and reverse the medical cause of the delirium. Directions for future research are suggested.

Numerous authors have noted a cluster of psychiatric signs and symptoms that may occur in patients who are treated in an intensive care unit (ICU) or high-dependency ward and have termed this syndrome ICU psychosis, postoperative delirium, and ICU syndrome; when patients have undergone heart surgery, it has been called postcardiotomy delirium or cardiac psychosis. Frequently, this syndrome is assumed to be peculiar to ICUs.

The aims of this article are to review the etiology and nature of this syndrome and then to discuss the implications of this review for nosology and management. Is there actually a psychiatric syndrome that is attributable to some feature of the ICU experience, or is this "syndrome" most accurately and most helpfully classified as a delirium? We argue that the latter is true and that it is possible and preferable to describe the disorder using established medical nomenclature. Appropriate classification will help to demystify the concept, ensure that crucial organic causes are sought and found, indicate optimal management, and facilitate standardized research.

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The critical care literature in the US has recently brought attention to the impact an ICU experience can have long after the patient survives critical illness, particularly if delirium was present. Current recommendations to mitigate post-intensive care syndrome (PICS) are embedded in patient and family-centered care and aim to promote family presence in the ICU, provide support for decision-making, and enhance communication with the health-care team. Evidence-based interventions are few in number but include use of an ICU diary to minimize the psychological and emotional sequelae affecting patients and family members in the months following the ICU stay. In this paper we describe our efforts to implement an ICU diary and solicit feedback on its role in fostering teamwork and communication between patients, family members, and ICU staff. Next steps will involve a PICS follow-up clinic where trained staff will coordinate specialty referrals and perform long-term monitoring of mental health and other quality of life outcomes.

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Modern critical care medicine has the ability to bring people from the brink of death and to keep people alive for much longer than in the past. It has now been known that these survivors can develop myriad mental and/or physical disabilities after treatment in the intensive care unit. In fact, up to 50% of patients who stay in the ICU for at least on week are susceptible to PICS. Research is now shedding light as to the severity and the need for education and post-care for patients and families as they deal with the aftermath of this.

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Within the last couple of decades, advances in critical care medicine have led to increased survival of critically ill patients, as well as the discovery of notable, long-term health challenges in survivors and their loved ones. The terms post-intensive care syndrome (PICS) and PICS-family (PICS-F) have been used in non-neurocritical care populations to characterize the cognitive, psychiatric, and physical sequelae associated with critical care hospitalization in survivors and their informal caregivers (e.g., family and friends who provide unpaid care). In this review, we first summarize the literature on the cognitive, psychiatric, and physical correlates of PICS and PICS-F in non-neurocritical patient populations and draw attention to their long-term negative health consequences. Next, keeping in mind the distinction between disease-related neurocognitive changes and those that are associated directly with the experience of a critical illness, we review the neuropsychological sequelae among patients with common neurocritical illnesses. We acknowledge the clinical factors contributing to the difficulty in studying PICS in the neurocritical care patient population, provide recommendations for future lines of research, and encourage collaboration among critical care physicians in all specialties to facilitate continuity of care and to help elucidate mechanism(s) of PICS and PICS-F in all critical illness survivors. Finally, we discuss the importance of early detection of PICS and PICS-F as an opportunity for multidisciplinary interventions to prevent and treat new neuropsychological deficits in the neurocritical care population.

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Doctors have gradually come to realize that people who survive a serious brush with death in the intensive care unit are likely to develop potentially serious problems with their memory and thinking processes.

This dementia, a side effect of intensive medical care, can be permanent. And it affects as many as half of all people who are rushed to the ICU after a medical emergency. Considering that 5.7 million Americans end up in intensive care every year, this is a major problem that until recently, has been poorly appreciated by medical caregivers.

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Post Intensive Care Syndrome-Family (PICS-F) refers to acute and chronic psychological effects of critical illness on family members of patients in intensive care units (ICU). Evidence about the increase and persistence of PICS-F warrants the need for prevention interventions. This study evaluated the feasibility of providing Sensation Awareness Focused Training (SĀF-T) during the ICU stay for spouses of mechanically ventilated patients. Methods: A randomized controlled trial of SĀF-T versus a control group was conducted (n=10) to assess safety, acceptability, feasibility, and effect size of the intervention on PICS-F symptoms. Symptoms assessed as outcome measures included stress, anxiety, depression, post-traumatic stress disorder, and sleep efficiency. Those randomly assigned to SĀF-T received one session daily over 3-days in the ICU. Repeated measures (day 1, day 3, day 30, and day 90) of PICS-F symptoms in both groups were analyzed. Results: Mean age was 58 ± 12 years; 70% were female. Feasibility success criteria were met in weekly recruitment (8 ± 3.5), enrollment rate (67%), SĀF-T acceptability (100% of doses received, no adverse events) with significantly lower post SĀF-T stress levels (p<.05) compared to pre SĀF-T stress levels, ActiWatch acceptability rate (90% agreed to wear, no adverse events) with no significant difference in sleep efficiency between groups (p>.05), and repeated measures completion rate (>90%). Conclusions: This study provided guidance for modifications to protocol outcome measures and evidence of a large effect size, which will inform a larger clinical trial to assess the effectiveness of the SĀF-T intervention in reducing PICS-F.

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More than 5.7 million patients are admitted to intensive care units (ICU) each year in the United States. Critical illness is a family crisis. There is strong evidence that family distress in response to critical illness does not disappear after ICU discharge. The Society of Critical Care Medicine has identified a cluster of complications that occur in family members of ICU patients as Post Intensive Care Syndrome-Family (PICS-F). PICS in family members of adult ICU survivors include symptoms of ongoing anxiety, depression, and post-traumatic stress disorder (PTSD). Data suggest that 70% of family members have symptoms of ongoing anxiety, and 33% have symptoms of depression and PTSD, which can persist for ≥4 years. Moreover, symptoms of anxiety, depression, and PTSD are higher and persist longer in family members than in adult ICU survivors. Because PICS-F occurs with greater frequency in spouses and surrogate health decision-makers, this study focused on participants whom are spouses of mechanically ventilated critically ill adults (typically sedated and unable to make their own health decisions).

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The number of ICU patients admitted annually continues to grow, with most recent estimates reaching 5.7 million. As there are growing numbers of critically ill patients, sepsis survivorship also has grown as a substantial public health concern, with a significant number of survivors diagnosed with post-intensive care syndrome (PICS). PICS is defined as a new or worsening impairment in mental, cognitive, or physical health status after critical illness and lasting beyond hospitalization for acute care. It is important to go beyond saving lives in the ICU and devote additional time and attention to preventing and treating the psychiatric, cognitive, and physical sequalae of ICU illness in the follow-up setting.

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Background

The sequelae of sepsis were once thought to be independent of sepsis itself and assumed to be either comorbid to sick patients or complications of critical illness. Recent studies have reported consistent patterns of functional disabilities in sepsis survivors that can last from months to years after symptoms of active sepsis had resolved.
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Post-sepsis syndrome is an emerging pathological entity that has garnered significant interest amongst clinicians and researchers over the last two decades. It is marked by a significantly increased risk of death and a poor health-related quality of life associated with a constellation of long-term effects that persist following the patient’s bout with sepsis. These include neurocognitive impairment, functional disability, psychological deficits, and worsening medical conditions.
Conclusion

This “post-sepsis syndrome” has been the subject of active preclinical and clinical research providing new mechanistic insights and approaches linked to survivor well-being. Here we review important aspects of these research efforts and goals of care for patients who survive sepsis.