For patients who survive critical illnesses, the need for care doesn’t end when they are discharged from the hospital. With advancements in critical care and increasing ICU survival, post-intensive care syndrome (PICS) is only expected to rise and will continue to be an important public health issue.
During the session Post-ICU Syndrome: Current Understanding, Implementation, and the Impact of COVID-19 on Tuesday, a panel of intensivists discussed the debilitating sequelae of PICS and the need for increased long-term recovery care and support for ICU survivors.
“This syndrome can be siloed into three different aspects—the physical impairments, the cognitive impairments, and the mental health effects,” said Radu Postelnicu, MD, Assistant Professor of Medicine in the Division of Pulmonary, Critical Care, and Sleep Medicine at NYU Grossman School of Medicine and Associate Director of the Medical Intensive Care Unit at Bellevue Hospital.
“With regard to the physical impairments, what it comes down to for a lot of patients in the ICU are the pulmonary manifestations. Many have significant respiratory problems after they leave the ICU, which has a significant impact on them as survivors of the ICU,” he said. “Additionally, these patients are often sedated and not moving and not working with physical therapy for prolonged periods of time, so their neuromuscular and physical functions decrease as well.”
Prolonged sedation, he said, can also contribute to an increased risk of cognitive impairment, which can be both acute and long term. The prolonged isolation from family and friends, combined with the inherent stress of experiencing a critical illness, can have long-term mental health effects, including depression, anxiety, and post-traumatic stress disorder (PTSD).
Over the course of the pandemic, intensivists have increasingly recognized significant overlap between PICS and the post-acute sequelae of COVID-19 (PASC) or what has been termed “long COVID.”
The additional burden on the health care system and the increased numbers of patients entering and leaving the ICU during the pandemic has intensified the need for dedicated resources and programs to support post-ICU recovery care for both patients and their caregivers, said Carla Sevin, MD, Associate Professor of Medicine and Director of the ICU Recovery Center at Vanderbilt University Medical Center.
Post-ICU care, she said, must begin before patients leave the hospital.
“When we think about the trajectory of recovery from critical illness in general, we’re rightly focused on the ICU side of things—we’re trying to save somebody’s life—but there’s a lot we can do in and after the ICU to make sure that our patients have a good recovery,” Dr. Sevin said. “As soon as someone starts to get better, our attention kind of drops off, and when they leave the hospital, we really don’t have the care systems in place to address things like early home adjustment and community adjustment. This creates a massive gap in care.”
Prior to the pandemic, Dr. Sevin said her institution and a few others had begun to establish dedicated post-ICU recovery clinics, mainly in tertiary centers, using a multidisciplinary team approach to care translated from the ICU into the clinic or the outpatient setting.
“But even before COVID-19, there were far fewer clinics than are needed to take care of all the patients who survived critical illness,” she said. “I think it’s important to acknowledge that following these post-ICU patients allows us to not only help patients and families, but to help ourselves learn the natural history of new diseases—like PICS and COVID—and to take that learning and feed it back upstairs to make our ICU care better.”
Lessons learned from the long-term effects of other critical illnesses, such as acute brain injury, can help inform standards of post-ICU care for illnesses like PICS and PASC, said Neha Dangayach, MD, Assistant Professor of Neurosurgery and Neurology and Research Co-Director for the Institute for Critical Care Medicine at the Icahn School of Medicine and Mount Sinai Health System.
“The need for preventing these long-term consequences is imperative,” she said. “When patients come into an ICU setting, no matter what the underlying disease process may be, upholding the principles of providing evidence-based, patient-centered care cannot be discounted.”
Managing patient expectations, she said, is paramount to providing effective post-ICU care.
“We need to recognize and prepare our patients for what will be a new state of ‘normal’ for them and put together resources that will help them get reintegrated back into society,” Dr. Dangayach said. “The main thing we have to remember is to focus on the person behind the patient. The ICU can be very dehumanizing, and we’ve got to remember that our patients have very rich identities and help them preserve that.”
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