Post Intensive Care Syndrome (PICS)

Muscle weakness, memory problems, depression, insomnia, physical pain, nightmares. These are just a few examples of the problems that patients may experience following critical illness. Symptoms such as these which affect emotional, physical, and cognitive health are now being recognized as Post Intensive Care Syndrome, or PICS. Efforts to educate health care providers, patients, and families about Post Intensive Care Syndrome are underway. Explore our site to learn more about PICS.

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Diagnosing PICS

Having a high index of suspicion is the most important factor in establishing a diagnosis of PICS as most ICUs do not have formal screening criteria for it.

  • Risk factors:
    • Physical
      • Prolonged bedrest/mechanical ventilation
      • Use of corticosteroids and neuromuscular blockers
      • Sepsis
      • Multiple organ failure
      • Hypoglycemia
    • Cognitive
      • Delirium
      • Sepsis
      • Acute respiratory distress syndrome
      • Pre-existing cognitive problems including dementia and alcoholism
    • Psychiatric
      • Prior psychiatric disorders
      • Use of sedating medications such as benzodiazepines
      • Memories of frightening ICU experiences
      • Presence of in-ICU psychologic distress symptoms and delusional experiences

 

  • Signs and symptoms:
    • Cognitive dysfunction
      • Most commonly people may experience problems with memory, attention, concentration, communication, ability to reason, plan and problem solve
      • These can range from subtle (such as difficulty performing a calculation) to severe (such as inability to care for oneself)
    • Psychological problems
      • Anxiety
      • Depression
      • Post-traumatic stress disorder
    • Physical debility
      • Generalized muscle weakness, difficulty with movement and walking
      • Inability to complete activities of daily living (dressing, bathing, grooming, feeding, toileting)
      • A great sense of fatigue or tiredness
      • Difficulty breathing, coughing or other airway problems
      • Not being able to swallow easily
      • Loss of feeling in the arms and leg

 

  • Diagnostic evaluation:
    • Cognitive function
      • Montreal Cognitive Assessment (MoCA) is the clinical instrument most applicable to use in the ICU population with score <26 indicating mild cognitive impairment and a score <18 indicating moderate to severe cognitive impairment consistent with dementia
    • Psychiatric evaluation
      • Hospital Anxiety and Depression Scale has been the most widely used and validated instrument in the ICU population to assess for symptoms of depression and anxiety; scores≥8 indicate significant symptoms of anxiety or depression
      • Impact of Events Scale-Revised has been the most widely used and validated instrument in the ICU population; scores≥1.6 indicate significant PTSD symptoms
    • Physical assessment
      • Performed by a physical therapist and/or occupational therapist
      • Should be done in the ICU to start early therapy and assess for outpatient rehabilitation needs
      • The Functional Status Score for the Intensive Care Unit (FSS-ICU) is used to evaluate a patient’s physical functioning in an ICU setting.  The scoring system is based on the validated Functional Independence Measurement (FIM). The FSS-ICU is scored on a scale of 0 – 35 with 0 indicating complete dependence and 35 indicating complete independence
    • Differential diagnosis
      • Important to know extent of the pre-ICU cognitive, mental and physical function
      • Stroke, hypo-/hyperthyroidism, abnormalities in liver and adrenal function, vitamin B12 deficiency, anemia, cancer, toxins and various medications, HIV and syphilis, and untreated obstructive sleep apnea can mimic various components of PICS

 

Prevention of PICS

Prevention of PICS is the most crucial part of its successful treatment. Minimizing sedation and early physical therapy have been found to be most beneficial. This can be best accomplished by the ABCDEF bundle approach.  Click here for more information: ICU Liberation site

Other measures include ICU diaries whereby family/caregiver journaling throughout the ICU stay can give a patient something to review/reflect on afterwards, providing a sense of closure and promoting memories of the events that actually took place over memories of delusions and hallucinations. This is thought to reduce rates of PTSD.

Early mobilization, which when started early in the ICU course, is safe even for those who still require mechanical ventilation. Patients can receive physical therapy during sedation interruption, and various forms of therapy can be applied based on patient’s clinical condition including in bed exercises, supine cycle ergometry, sitting on the edge of the bed, transferring to a chair, standing or marching in place, and walking.

 

Treatment

Treatment of PICS depends on the area of function affected by the condition. Discussion with the patient and family during hospitalization can help identify potential problems early. Appropriate post-ICU services may be needed to provide support for cognitive dysfunction, mental health services, physical and occupational therapy and rehabilitation, and social support.

  • Cognitive dysfunction
    • Can be managed non-pharmacologically primarily by addressing other issues that can contribute to it
  • Anxiety, depression, PTSD
    • Can be treated with psychotherapy and medications or a combination of both
  • Physical dysfunction
    • Can be treated by physical and occupational therapists in inpatient and outpatient settings. In addition to an exercise program, patients may require assistance with adjusting their environment to their new needs and with obtaining mobility aids

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