Post-intensive care syndrome (PICS): Treatment and prognosis

INTRODUCTION — Many survivors experience impairment in cognition, mental health, and physical function, known as post-intensive care syndrome (PICS). The mental health of family members may also be adversely affected, which is termed PICS-family (PICS-F).

In this topic, we review the prevention, treatment, and outcome of PICS and PICS-F. The epidemiology, clinical manifestations, and diagnostic evaluation of PICS and PICS-F are discussed separately. (See "Post-intensive care syndrome (PICS) in adults: Clinical features and diagnostic evaluation".)

DEFINITION

●PICS – Although there is no official definition for PICS, most clinicians agree that PICS constitutes new or worsening function in one or more of the three domains after critical illness (figure 1) [1]:

•Cognitive function

•Psychiatric function

•Physical function

●PICS-family – The term PICS-family (PICS-F) has been coined to encompass the effects of critical illness on acute and chronic psychologic morbidity among patients' caregiver/family members [1]. It is considered the caregiver/family response to the stress of critical illness in a loved one. It includes the symptoms that are experienced by caregiver/family members during the critical illness as well as those that occur following death or discharge of a loved one from the intensive care unit (ICU). (See "Post-intensive care syndrome (PICS) in adults: Clinical features and diagnostic evaluation", section on 'Post-intensive care syndrome-family'.)

PREVENTION — In our experience, the most effective strategy to prevent PICS is to prevent critical illness. However, once critical illness has developed, the most effective strategy to prevent PICS is one that minimizes sedation and prioritizes early physical rehabilitation during the intensive care unit (ICU) stay and recovery process.

Prevention of critical illness — The prevention of critical illness is challenging but includes strategies such as vaccination, which reduces the risk of hospitalization or death related to coronavirus disease 2019 (COVID-19). As another example, in patients with acute exacerbations of chronic obstructive pulmonary disease, noninvasive ventilation decreases the need for intubation and mechanical ventilation. (See "COVID-19: Vaccines" and "Noninvasive ventilation in adults with acute respiratory failure: Benefits and contraindications", section on 'Hypoxemic nonhypercapnic respiratory failure not due to ACPE'.)

ABCDEF bundle — To minimize the likelihood of developing PICS in critically ill patients, particularly in those receiving mechanical ventilation, we use the ABCDEF bundle approach, much of which is discussed in the linked topics [2-6]:

●Awakening and Breathing Coordination with daily sedative interruption (DSI) and ventilator liberation practices [7]. (See "Initial weaning strategy in mechanically ventilated adults", section on 'Choosing a weaning method' and "Sedative-analgesia in ventilated adults: Management strategies, agent selection, monitoring, and withdrawal".)

●Delirium monitoring and management [8,9]. (See "Delirium and acute confusional states: Prevention, treatment, and prognosis".)

●Early ambulation in the ICU, when feasible [10-13]. (See 'Early ambulation/physical therapy' below.)

●Family empowerment and engagement. (See 'ICU diaries' below and 'Post-intensive care syndrome-family' below.)

Evidence to support this practice is derived from a prospective cohort study of over 15,000 ICU adults, which reported that use of the ABCDEF bundle was associated with a lower likelihood of death within seven days (hazard ratio [HR] 0.32, 95% CI 0.17-0.62), next-day mechanical ventilation (odds ratio [OR] 0.28, 95% CI 0.22-0.36), and coma (OR 0.35, 95% CI 0.22-0.56), as well as delirium, physical restraint use, and ICU readmission [14]. There was a dose-response relationship between the components of bundle use and these outcomes. In another randomized trial of 758 critically ill patients, a tailored multicomponent program decreased self-perceived discomfort in adult critically ill patients compared with standard care [15]. In an extension of this study, the same program reduced the prevalence of posttraumatic stress disorder (PTSD) symptoms at one year [16].

Awakening and breathing coordination — In mechanically ventilated patients, we adopt the practice of light sedation (eg, 0 to -1 on the Richmond agitation-sedation scale (table 1)) together with a DSI and awakening trial and daily assessment of readiness to wean.

Limited data support this practice to prevent PICS. As an example, patients who underwent DSI experienced lower Impact of Events score (27.3 versus 11.2) and lower rates of PTSD (32 versus 0 percent) compared with patients who did not undergo DSI [17]. Additional data to support the value of light sedation and DSI are discussed separately. (See "Initial weaning strategy in mechanically ventilated adults", section on 'Choosing a weaning method' and "Sedative-analgesia in ventilated adults: Management strategies, agent selection, monitoring, and withdrawal".)

Delirium management — Delirium is a key risk factor for cognitive dysfunction, which is a component of PICS. The prevention and management of delirium are discussed separately. (See "Delirium and acute confusional states: Prevention, treatment, and prognosis".)

Early ambulation/physical therapy — In general, our approach is to mobilize ICU patients as soon as is feasible, ideally on the first ICU day and in a graduated manner, provided that the patient is stable from a cardiovascular, respiratory, and neurologic standpoint. Stable or weaning doses of vasopressors and mechanical ventilation should not be barriers to mobilization. Although evidence is conflicting, this approach is supported by the American Thoracic Society, American College of Chest Physicians, and Society of Critical Care Medicine [4,5,18].

In our practice, we begin with passive range of motion and, depending on patient tolerance, escalate to sitting up in bed or a chair, standing bedside for limited periods, and rarely gentle ambulation, if feasible. However, the components of early ambulation/physical therapy (PT) vary by study, institution, and patient tolerance. Factors that influence the ability to institute early PT strategies include the presence of mechanical and noninvasive ventilation, the degree of sedation, medical conditions or organ failure (eg, encephalopathy, respiratory failure, hemodynamic instability, renal failure requiring hemodialysis), and underlying comorbidities (eg, neuromuscular disorder).

Several studies report that early ambulation/PT within the first 72 hours may be beneficial and improve physical function, length of stay, and duration of mechanical ventilation [4,10,11,13,19-25]. As examples:

●A 2022 meta-analysis of 60 studies including 5352 patients demonstrated that early mobilization improved physical function at hospital discharge (standardized mean difference 0.22, 95% CI 0.00-0.44) and reduced ICU length of stay (mean difference -0.80 day; 95% CI -1.37 to -0.23 day) and hospital length of stay (mean difference -1.75 day, 95% CI -3.03 to -0.48 day) [25].

●An older 2017 meta-analysis of four trials reported that interventions targeted at early mobilization when compared with usual care were associated with increased ambulation at discharge (64 versus 41 percent) and a shorter duration of mechanical ventilation (mean difference 2.7 fewer days) [4].

In contrast, other trials report minimal, no benefits, or possible harm associated with early and/or aggressive PT interventions in the ICU [26-31]. As examples:

●In a 2023 meta-analysis of 15 trials (2703 patients), early mobilization was associated with a 75 percent increase in the probability of being alive and out of the hospital at six months compared with standard care. However, early mobilization also resulted in a 66 percent probability of increased adverse events and a 72 percent probability of increased six-month mortality [31].

●In a randomized trial of 750 patients undergoing mechanical ventilation, increased early aggressive mobilization (sedation minimization and daily physiotherapy) did not impact the number of days alive outside of the hospital or three-month mortality when compared with usual care [30]. In addition, among survivors, there was no difference in cognitive and psychologic function, quality of life, and disability at 180 days. Increased mobilization was associated with increased adverse events (9 versus 4 percent, mostly, arrhythmia, oxygen desaturation, and altered blood pressure). However, in contrast to earlier studies, which typically begin with range of motion and escalate depending upon patient tolerance and stability, the intervention in this trial was comparatively aggressive. In addition, since 40 percent of patients in the usual care group were able to walk with assistance, this may have minimized the difference between the groups and suggests the absence of a difference may reflect both the usual care and the intervention group being above a critical threshold of mobilization to improve outcomes.

●Two randomized, multicenter trials testing early aggressive PT during the post-ICU hospital stay or later in the ICU stay (240 and 120 patients, respectively) reported no improvement in physical recovery, mental health, or health-related quality of life (HRQOL), although these studies had limited power to rule out a smaller but clinically meaningful effect [27,28].

Family empowerment — We promote the liberalized presence of caregiver/family members and their involvement in patient care (eg, applying lip balm or massage and documenting daily activities in a diary). However, the impact of caregiver/family empowerment on patient outcomes is uncertain. In one study, family presence was associated with decreased delirium prevalence among elective surgery patients with intact Glasgow Coma Scale score but not among medical or emergency surgery patients [32,33]. In a separate, multicenter study of critically ill patients with COVID-19, in-person or virtual family presence was associated with a lower rate of delirium [34]. Other examples of caregiver/family participation are discussed below. (See 'Prevention' below.)

Therapies of uncertain benefit

ICU diaries — Keeping a diary of daily ICU activities is thought to foster the formation of factual memories lost by the patient during their ICU stay. However, data are conflicting.

●Several small prospective or randomized studies have shown a reduction in symptoms of PTSD when an ICU diary was maintained prospectively during the patient's ICU stay by caregiver/family members, health care providers, or both and paired with a debrief where the journal is reviewed with the patient by a health care provider [35-38].

●In contrast, a randomized trial of 657 patients who received mechanical ventilation for at least two days in the ICU reported a similar prevalence of PTSD symptoms at three months after ICU discharge among patients who received ICU diary intervention compared with those who did not (in 30 versus 34 percent) [39]. In contrast with prior studies, debrief post-discharge was not included as part of the intervention in the trial.

Diary implementation can be challenging, with administrative, informational, and operational difficulties, although some institutions have developed systems that overcome these challenges [40].

Avoiding hypoglycemia and hypoxemia — We provide care known to optimize neurologic outcomes including avoiding hypoglycemia and hypoxemia, when feasible. Limited data suggest that the use of an insulin protocol, titrated to normoglycemia, may reduce the rate of ICU-acquired weakness [12,41]. The impact of oxygenation targets on PICS outcomes is unknown. Data that support these practices for other benefits are discussed separately. (See "Evaluation and management of the nonventilated, hospitalized adult patient with acute hypoxemia", section on 'Oxygen saturation goals' and "Overview of initiating invasive mechanical ventilation in adults in the intensive care unit", section on 'Fraction of inspired oxygen'.)

Miscellaneous

●Early cognitive therapy – Data on the value of early cognitive therapy delivered during the ICU stay are conflicting and limited [42-44]. Further study is required to examine the efficacy of this strategy. (See "Overview of psychotherapies", section on 'Cognitive and behavioral therapies'.)

●Glucocorticoids – Although the administration of glucocorticoids has been reported to reduce the risk of PTSD [45], they should not be administered solely for this indication.

TREATMENT — Treatment of PICS involves treating symptoms associated with the individual domains of PICS. In most cases, a multidisciplinary approach is needed, which has led to the development of PICS clinics staffed with experts in PICS care and peer support groups. Several societies have also published guidelines for patients to promote patient advocacy in this regard.

Individual components of PICS — For intensive care unit (ICU) survivors with the signs and symptoms of PICS, we treat each component accordingly and seek appropriate post-ICU discharge services (eg, cognitive, mental health, physical therapy [PT], occupational rehabilitation, social support).

The individual components of PICS are interdependent. For example, physical rehabilitation initiated early in critical illness may decrease cognitive impairment and psychiatric morbidity as well as improve physical function [10,19,28,46].

Many benefits of specific therapy (eg, cognitive treatments) are unproven in PICS but are typically used based upon data extrapolated from populations with similar deficits (eg, dementia, stroke, motor vehicle accidents, developmental delay).

The general management and follow-up of cognitive, mental, and physical deficits in PICS are discussed in the following sections:

●Cognitive deficits – (see "Mild cognitive impairment: Prognosis and treatment")

●Anxiety – (see "Generalized anxiety disorder in adults: Management" and "Complementary and alternative treatments for anxiety symptoms and disorders: Herbs and medications")

●Depression – (see "Unipolar major depression in adults: Choosing initial treatment" and "Bipolar major depression in adults: Efficacy and adverse effects of antidepressants")

●Posttraumatic stress disorder (PTSD; including sexual dysfunction) – (see "Posttraumatic stress disorder in adults: Psychotherapy and psychosocial interventions" and "Overview of sexual dysfunction in females: Management" and "Treatment of male sexual dysfunction")

●Physical dysfunction (including lung dysfunction) – (see "Geriatric rehabilitation interventions" and "Cardiac rehabilitation in patients with heart failure" and "Pulmonary rehabilitation" and "Physical rehabilitation for cancer survivors")

●Malnutrition – (see "Geriatric nutrition: Nutritional issues in older adults", section on 'Treatment of weight loss' and "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription")

●Poor sleep – (see "Approach to the patient with excessive daytime sleepiness", section on 'Management' and "Insufficient sleep: Evaluation and management", section on 'Management')

Long term multidisciplinary follow-up — Most patients need follow-up for years at appropriate intervals (initially every two to three months) that are individualized to the unique needs of each patient. We evaluate patients within two to four weeks of hospital discharge [47] and advocate re-evaluation should patients move from one facility to another (eg, rehabilitation facility to home).

The care of this population is best done with a multidisciplinary team approach that includes internists, specialist providers, social services, occupational and physical therapists, and sometimes peer support groups. Communication between in-hospital providers and outpatient or rehabilitation facility providers should be optimized, including functional reconciliation that takes into consideration a patient's pre-ICU abilities and documents their current abilities for all three domains of PICS upon discharge from the ICU, rehabilitation facility, or home.

PICS clinics — PICS clinics have been introduced in both the United States and the United Kingdom in recognition of the need for the care of patients and families with medical, mental health, social support, and counseling requirements after critical illness [48-53].

A growing body of literature exists that provides practical advice for establishing ICU recovery programs [54-57], and evidence is emerging that describes the benefits of these programs, including improved medication reconciliation [37,58-64]. However, more robust evidence is needed to demonstrate improved clinically important outcomes from PICS clinics in critical illness survivors.

●One systematic review of eight randomized trials examining several interventions for PICS identified that aftercare by an ICU follow-up clinic reduced the Impact of Event Scale (an indicator of PTSD) for females [37].

●In contrast, a multicenter randomized trial of 291 survivors of sepsis and septic shock reported that a primary care clinician-based team intervention that included clinician contact, education, subspecialist referral, and medications administered by trained personnel did not improve mental health-related quality of life (HRQOL; measured by mental health summary scores) six months after ICU discharge [59]. However, the baseline mental health scores were close to population norms and patients with significant cognitive dysfunction were excluded from the trial, which may have limited the detection of a potential benefit from the team intervention.

●Several case series describing specific post-ICU programs reported that a five-week, complex multidisciplinary rehabilitation program initiated 12 weeks after hospital discharge was associated with improved HRQOL, improved self-efficacy scores, and fewer symptoms of depression [60-62]. Their benefits were sustained to one-year postintervention.

Peer support therapy — Peer support groups are a novel strategy for the management of PICS [48,65]. When used after cardiac surgery, myocardial infarction, trauma, and pediatric critical care, peer support appears to reduce psychologic distress and increase social support [66]. Additional benefits that may result from a peer support community include the provision of empathy and practical advice to facilitate recovery as well as patient input into outcomes that are important to them as a group.

PROGNOSIS — The signs and symptoms of PICS improve modestly over the first 6 to 12 months following discharge from the intensive care unit (ICU). However, in many patients, deficits persist for years, particularly the cognitive and psychologic deficits. PICS is frequently associated with the inability to return to work and decreased quality of life as well as an increased risk of rehospitalization and death over the subsequent few years [67]. The effect of preventive or therapeutic interventions on these outcomes is unknown. Whether patients with a prior history of PICS are at increased risk for recurrent PICS is unknown. The public health burden of PICS is substantial due to the presence of neuropsychologic and functional disability that occurs in association with PICS [68-70].

Cognitive, psychiatric, and physical impairments — Reported outcomes among the individual components of PICS include the following:

●Cognitive impairments – Cognitive function may improve over the first 6 to 12 months. However, in the vast majority, the improvements are small and the impairment persists for years [71-76]. This was best illustrated in the largest study of ICU survivors, up to 40 percent of whom had cognitive impairment, that reported minimal improvements in cognition between 3 and 12 months [76]. In addition, it has been implied that impaired cognition is particularly associated with poor outcomes in the other aspects of PICS such as psychiatric impairment, inability to return to work, and decreased quality of life [71-75].

●Psychiatric impairments – Psychiatric sequelae of critical illness may also improve but typically persist for years. While most studies report persistent anxiety and depressive symptoms at 12 months [69,76], some observational studies report symptoms of posttraumatic stress disorder (PTSD) lasting for up to eight years [69,76-80]. As an example, a population-based cohort study of over 9000 patients who survived mechanical ventilation reported that between 3 and 12 months following discharge from the ICU, there was a cumulative increase in the incidence of the prescription of psychoactive medications (from 13 to 19 percent) [77].

●Physical impairments – Compared with the other domains of PICS, physical dysfunction following critical illness is more likely to improve, particularly over the first 12 months.

A prospective multicenter study of 222 ICU survivors reported that 36 percent had physical dysfunction on discharge that improved over the first 12 to 24 months (14 and 9 percent, respectively) [81]. This study did not include patients with primary neurologic deficits (eg, stroke, traumatic brain injury), poor prognosis from a pre-existing illness, or prior lung resection in whom physical dysfunction may be more prolonged.

The rate of improvement may also be slower in those with physiologically documented polyneuromyopathy and in those receiving prolonged mechanical ventilation [81,82].

Long-term survival — The risk of death remains elevated in patients after critical illness, particularly in the first three to six months after an ICU admission [83-87]. The reason for poor survival in this population is unknown but is likely multifactorial and related to pre-existing illnesses, new impairments, a decline in pre-existing organ dysfunction, and/or comorbidities that predispose to acute illness.

●One national registry database study that included over 9000 ICU survivors reported that one-, two-, and three-year mortality rates were 13, 19, and 28 percent, respectively [85]. Medical patients and those with cancer had higher mortality rates compared with elective and cardiac surgical patients (hazard ratio [HR] 1.4 and 1.9, respectively).

●Another retrospective cohort study of over 35,000 Medicare beneficiaries reported that ICU survivors had a higher three-year mortality compared with age- and sex-matched hospital and general population controls (40 versus 36 and 15 percent, respectively) [86]. Similar mortality findings have been reported in Scotland and Canada [87,88].

●Another database study reported that ICU survivorship was associated with a higher five-year mortality when compared with non-ICU patients discharged from hospital (32 versus 22 percent) [87]. Similarly, a study of sepsis survivors also reported increased mortality at one year (HR 2.18, 95% CI 2.14-2.22) as well as increased rates of major cardiovascular events and stroke when compared with the general population and patients hospitalized for a nonsepsis diagnosis [89].

The subgroups at greatest risk of death after ICU discharge include the following [84-86,88,90-92]:

●Patients from medical ICUs (as opposed to surgical ICUs)

●Patients with sepsis (see "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis" and "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis", section on 'Prognosis')

●Patients with malignancy (see "Prognosis of cancer patients in the intensive care unit")

●Patients requiring mechanical ventilation (eg, for acute respiratory distress syndrome) (see "Acute respiratory distress syndrome: Prognosis and outcomes in adults")

●Patients discharged to a skilled nursing or long-term acute care facility (see "Management and prognosis of patients requiring prolonged mechanical ventilation", section on 'Outcomes')

●Patients with neuromuscular weakness (see "Neuromuscular weakness related to critical illness")

●Patients with renal failure (see "Kidney and patient outcomes after acute kidney injury in adults")

Health-related quality of life — Health-related quality of life (HRQOL) is significantly lower in survivors of critical illness. In a systematic review that included 53 studies, ICU survivors consistently reported lower quality of life compared with age- and sex-matched controls [93-95]. (See "Evaluation of health-related quality of life (HRQL) in patients with a serious life-threatening illness".)

In general, HRQOL improves modestly over time but does not return to baseline [93,94]. One prospective multicenter study of 1663 patients who survived ICU admission reported persistently low HRQOL for up to 36 months with only small improvements recorded during that period [76,96].

Most of the poor HRQOL may be due to pre-existing disease, with one prospective study suggesting that the majority of the reduction in HRQOL following ICU care was attributable to quality of life-related effects of pre-existing illness (eg, chronic lung disease, malignancy) [94].

Quality of life is worst among those with acute respiratory distress syndrome, prolonged mechanical ventilation, severe sepsis, trauma, and malignancy [73,90,97-102]. Patients at greatest risk of reduced HRQOL are those with cognitive impairments, psychiatric symptoms, poor sleep quality, and pulmonary and sexual dysfunction [45,72,73,97,102-105].

Post-ICU rehospitalization and ongoing medical care — The risk of rehospitalization is elevated after critical illness, and the risk persists for years [106]. As many as one-quarter of these early rehospitalizations include another ICU stay. Among sepsis survivors, as many as one-quarter of patients are readmitted within 30 days, many with another life-threatening infection [107-111]. Compared with noncritically ill hospitalized patients, survivors of critical illness required more frequent rehospitalizations (4.8 versus 3.3 readmissions per person over five years [87] in Scotland; 65.3 versus 49.7 percent rehospitalization in Canada) [88].

More than 40 percent of these rehospitalizations are for diagnoses that might be preventable with improved access to ambulatory follow-up care [110].

One study suggested that sepsis survivors discharged to home health care who receive early and intense home health visits, paired with physician follow-up within seven days, experience lower rates of rehospitalization at 30 days [112].

Return to work — Related, in part, to ongoing medical care needs, reduction in employment after critical illness is common. Consequently, many survivors remain unemployed at 3 and 12 months after critical illness, leading to financial burden as another patient-important outcome affected by ICU admission [69,113]. A negative impact on family income was reported by one-third to one-half of patients and families of survivors [69].

POST-INTENSIVE CARE SYNDROME-FAMILY — We advocate for liberalized caregiver/family presence as well as good communication strategies between staff and caregiver/family members of survivors of critical illness. This may also involve an appointed staff member to help navigate the caregiver/family through the process. We target treatment efforts at individual symptoms similar to the approach outlined for patients. The symptoms of PICS-family (PICS-F) improve over time but may last for months or years.

Prevention — We practice the following preventive measures to reduce potential future suffering from PICS-F while patients are still in the intensive care unit (ICU):

●Liberalized caregiver/family presence – A multicenter, randomized trial found that a more flexible family presence policy reduced anxiety and depression scores among caregiver/family members of critically ill patients without increasing burnout among the clinical team [32].

When physical presence is limited, we encourage telephone and teleconferencing between the patient and their families/caregiver, although outcome data are limited [114].

●Structured communication approaches – We support the guidelines from the American College of Critical Care Medicine and Society of Critical Care Medicine that advocate for the use of structured caregiver/family meetings and caregiver/family-centered rounds, which may reduce anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms among caregiver/family members [115,116]. For example, when caregivers/family participate in rounds, benefits include decreasing caregiver/family stress and anxiety and improving communication and confidence in the care team [117-120]. It does not significantly increase the duration of rounds and may, in fact, reduce total meeting time [118,121-123]. Caregiver/family-centered rounds also meet the caregiver/family's desire for regular and less formal meetings [124]. In another study, the use of structured communication, which was guided by the mnemonic "VALUE" (Value family statements, Acknowledge family emotions, Listen to the family emotions, Understand patient as a person, Elicit family questions) resulted in both greater caregiver/family participation in and length of caregiver/family meetings.

●Increasing access to information – One prospective study of 551 relatives reported that an information brochure and website designed to meet the caregiver/family's needs reduced PTSD symptoms [125].

Additional measures to reduce PICS-F may include:

●Caregiver/family navigator – A randomized clinical trial found that the use of a trained nurse or social worker facilitator reduced depressive symptoms among caregiver/family members at six months. This approach also resulted in decreased ICU costs and substantially reduced length of stay among patients dying in the ICU [126]. Another multicenter randomized clinical trial using trained nurses for caregiver/family support and communication also found shorter length of stay among decedents, improved communication, and caregiver/family-centeredness, although no effect was found on the rates of family anxiety or depression at six months [127].

●Caregiver/family participation in bedside care – Caregiver/family members participating in the bedside care of their adult loved ones through a menu of activities have reduced anxiety levels [128]. This may involve applying lip balm or massage, reading aloud, or talking about daily events [129].

●Diaries – Keeping a diary has uncertain benefit. While one trial reported no difference in PTSD, anxiety, or depression symptoms in caregiver/family members who kept ICU diaries [39], another trial reported lower posttraumatic stress scores among family members who participated in authoring ICU diaries [130].

Treatment — For patients who suffer from PICS-F, we target treatment efforts at individual symptoms similar to the approach outlined for patients, which is described in detail above. (See 'Individual components of PICS' above.)

Prognosis — The symptoms of PICS-F improve over time but may be long-lasting. The impact of preventive or therapeutic measures on the prognosis is unknown.

Following discharge of the loved one from the ICU, the proportion of caregiver/family members suffering these symptoms decreases over time but remains present in approximately one-quarter to one-third at six months [131-141]. For some, symptoms persist for years (eg, those with a low quality of life) [139].

Commonly, their health-related quality of life (HRQOL) is also poor, and in one study, approximately 36 percent were taking anxiolytic or antidepressant drugs and 8 percent were prescribed psychotropic agents following discharge or death of the patient [142].

Many individuals have changes in or lose employment following death or discharge of a loved one and suffer from financial stress, which, in turn, likely contributes to prolonged symptoms [69,143].

USEFUL LINKS — Additional details on the rehabilitation of patients following critical illness can be found from guidelines issued by the National Institute for Health and Care Excellence. Support for patients and family member following critical illness can also be found at the ARDS Foundation, the ARDS Foundation Canada, Healthtalk: Patients’ experiences, Healthtalk: Experiences of family and friends and The Society of Critical Care Medicine's Thrive initiative. Systematically collected, curated, and analyzed patient stories of their ICU experience the United Kingdom are available from healthtalk.org.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Post-intensive care syndrome (PICS) (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Definition – The term post-intensive care syndrome (PICS) encompasses new or worsening function in one or more of the three domains after critical illness (figure 1): cognitive function, psychiatric function, physical function. (See 'Definition' above.)

●Prevention – Our general approach is the following:

•The most effective strategy to prevent PICS is to prevent critical illness. (See 'Prevention of critical illness' above.)

•Among those who are critically ill, using the ABCDEF bundle has been widely adopted. Support for this approach is based upon data that report improved outcomes with bundled care (eg, lower likelihood of death, mechanical ventilation, and symptoms of posttraumatic stress disorder [PTSD]). The ABCDEF bundle largely applies to patients who are mechanically ventilated and involves the following:

-Awakening and Breathing Coordination with daily sedative interruption (DSI) and ventilator liberation practices – In mechanically ventilated patients, we adopt the practice of light sedation (eg, 0 to -1 on the Richmond agitation-sedation scale (table 1)) together with a daily awakening trial. We also perform daily assessment of readiness to wean. Guidance and supporting data regarding these practices are discussed separately. (See "Initial weaning strategy in mechanically ventilated adults", section on 'Choosing a weaning method' and "Sedative-analgesia in ventilated adults: Management strategies, agent selection, monitoring, and withdrawal".)

-Delirium monitoring and management – Delirium is a key risk factor for cognitive dysfunction, which is a component of PICS. The prevention and management of delirium are discussed separately. (See "Delirium and acute confusional states: Prevention, treatment, and prognosis".)

-Early ambulation in the intensive care unit (ICU) – We suggest mobilizing ICU patients as soon as is feasible (eg, first ICU day) rather than bedrest (Grade 2C). This approach is based upon several studies that report improved physical function when early ambulation is practiced in the ICU, although data are conflicting. Depending on patient tolerance, we begin with passive range of motion and, depending on patient tolerance, escalate to sitting up in bed or a chair, standing bedside for limited periods, and rarely gentle ambulation. (See 'Early ambulation/physical therapy' above.)

-Family empowerment and engagement – We promote the liberalized presence of caregiver/family members and their involvement in patient care (eg, applying lip balm or massage and documenting daily activities in a diary). However, the impact of caregiver/family empowerment on patient outcomes is uncertain. (See 'Family empowerment' above.)

•Other therapies such as keeping an ICU diary, avoiding hyperglycemia and hypoxemia, and administering cognitive therapy in the ICU are of uncertain benefit from a PICS prevention perspective. (See 'Therapies of uncertain benefit' above.)

Other benefits associated with avoiding hyperglycemia and hypoxemia are discussed separately. (See "Evaluation and management of the nonventilated, hospitalized adult patient with acute hypoxemia", section on 'Oxygen saturation goals' and "Overview of initiating invasive mechanical ventilation in adults in the intensive care unit", section on 'Fraction of inspired oxygen'.)

●Treatment – Treatment of PICS involves treating manifestations associated with the individual domains of PICS with additional referral to appropriate health care personnel when necessary. In most cases, a multidisciplinary approach is needed, which has led to the development of PICS clinics and peer support groups. (See 'Treatment' above.)

This information is discussed in detail in the following topics:

-Cognitive deficits – (see "Mild cognitive impairment: Prognosis and treatment")

-Anxiety – (see "Generalized anxiety disorder in adults: Management" and "Complementary and alternative treatments for anxiety symptoms and disorders: Herbs and medications")

-Depression – (see "Unipolar major depression in adults: Choosing initial treatment" and "Bipolar major depression in adults: Efficacy and adverse effects of antidepressants")

-PTSD (including sexual dysfunction) – (see "Posttraumatic stress disorder in adults: Psychotherapy and psychosocial interventions" and "Overview of sexual dysfunction in females: Management" and "Treatment of male sexual dysfunction")

-Physical dysfunction (including lung dysfunction) – (see "Geriatric rehabilitation interventions" and "Cardiac rehabilitation in patients with heart failure" and "Pulmonary rehabilitation" and "Physical rehabilitation for cancer survivors")

-Malnutrition – (see "Geriatric nutrition: Nutritional issues in older adults", section on 'Treatment of weight loss' and "Nutrition support in intubated critically ill adult patients: Initial evaluation and prescription")

-Poor sleep – (see "Approach to the patient with excessive daytime sleepiness", section on 'Management' and "Insufficient sleep: Evaluation and management", section on 'Management')

●Outcomes – The signs and symptoms of PICS improve modestly over the first 6 to 12 months following discharge of the patient from the ICU. However, in many patients, deficits persist for years, particularly the cognitive and psychological manifestations. PICS is frequently associated with the inability to return to work and decreased quality of life as well as an increased risk of rehospitalization and death over the subsequent few years. The effect of preventive or therapeutic interventions on these outcomes are unknown. (See 'Prognosis' above.)

●PICS-F – PICS-family (PICS-F) has been coined to encompass the effects of critical illness on acute and chronic psychologic morbidity among patients' caregiver/family members. We advocate for liberalized caregiver/family presence as well as good communication strategies between staff and caregiver/family members of survivors of critical illness. This may also involve an appointed staff member to help navigate the caregiver/family through the process. We target treatment efforts at individual symptoms similar to the approach outlined for patients. The symptoms of PICS-F improve over time but may last for months or years. (See 'Post-intensive care syndrome-family' above.)