Post–Intensive Care Syndrome and Chronic Post-ICU Pain

• Post-intensive Care Syndrome (PICS) is a condition that occurs when the patient is in the ICU, but continues even after the patient returns home.
• PICS may involve body, mind, thoughts or feelings of the patient and may even affect family members.
• Nearly 80% of patients admitted to the ICU develop cognitive problems like thinking ability and memory lapses that last, sometimes, even for years.

The Intensive Care Unit is a medically controlled environment that is designed to support the medical needs of a patient, to improve lifespan and also to improve the quality of a patient’s life. The patient-centric measures that have been devised for supporting a patient’s medical condition lead to effects that last for a few months or even years after the patient had been discharged from the ICU. According to the Society of Critical Care at The Johns Hopkins University:

• Post-traumatic Stress Syndrome is witnessed among one in three patients who require the support of a breathing machine.
• An ICU stay has been found to increase depression in 50% of patients.
• Muscle weakness due to ICU care occurs among
• 50% of patients undergoing treatment for sepsis.
• 50% of patients with a stay in the ICU that lasts longer than 7 days.
• 33% of patients who require the support of a ventilator.

The muscle weakness can last longer than a year in many instances.

Post-ICU Syndrome

Critically ill patients who are admitted to the ICU and are forced to receive treatment for a period of time in this medically monitored system are at an increased risk for the following conditions:

• Pain
• Weakness
• Anxiety
• Prolonged necessity for organ support
• Deficit in concentration
• Confusion
• Increased time required to process information
• Lowered visual spatial resolution
• Post-traumatic stress disorder
• Lowered ability to complete tasks
• Memory lapses

Even 1 to 5 years after being discharged from an ICU, the patient may suffer from:

• Difficulty in movement
• Depression
• Lack of social skills
• Increased risk for falls
• 34% show a decline in cognitive ability

The post-ICU syndrome includes physical, psychological and neurological symptoms that affect individuals who have stayed in the ICU for long periods of time. Patients suffering from sepsis, which is a stage of infection that is called ‘blood poisoning’, are at a higher risk of developing ICU-induced delirium, though other ICU patients may also develop this condition.

ICU-induced Delirium

Delirium is a state of confusion when a person is unable to think clearly and process information. The patient may also ‘see’ things that are not there or experience situations that do not actually occur.

Delirium may be caused by:

• A lack of oxygen to the brain
• Medications
• Being on ventilator support for long periods
• Severe pain
• Painkillers

Since a large number of patients who undergo treatment for sepsis in an ICU develop delirium, doctors are now treating this condition more aggressively, to lower the period of stay in an ICU. Pro-active steps are being taken to ensure that the patient is dependent on the ventilator for fewer periods with active support to get the patient walking soon after treatment. The dosages of medications are also checked routinely to lower incidences of drug-induced delirium.

Patients who remain in the ICU for long periods of time are prone to returning home and gaining weight with little movement due to increased family support and care. This increases their time of recovery and leads to many disabilities. Post-ICU syndrome can be effectively treated by including family members in the active rehabilitation of the patient by encouraging recovery through careful mobilization of the patient.

More than 80% of patients suffer from depression, either due to disability induced by their condition or due to perceived disability. Psychological support from trained professionals will aid such patients in leading a more normal lifestyle.

Studies Associated with Post-ICU Syndrome

In a Brazilian study that focused on patients receiving treatment at a single center, 690 patients discharged after receiving treatment in the ICU were studied.

• 27% of the patients died
• 18% were readmitted into the ICU
• 40% were readmitted to the hospital
• 52% required at least a single emergency visit to the hospital
• 11% of the patients required psychological counseling or support

The risk of death among patients who received treatment  in  the ICU was associated with severity of organ dysfunction and severity of post-ICU syndrome rather than the underlying disease condition that required ICU care.

Australian Cohort Study of Pneumonia Patients Treated in ICUs

An Australian cohort study examined the effects of treatment received in an ICU among patients suffering from severe Influenza (H1N1) pneumonia and with a mean age of 36 years. These patients required Extracorporeal Respiratory Support (ECMO- Extracorporeal Membrane Oxygenation) for a median number of 11 days. This study highlighted that though 85% of patients survived, only 26% of patients returned to work after a period of 8 months while the others suffered from ICU-induced disabilities.

The increased disabilities associated with post-ICU syndrome warrant better management of patients in the ICU set up with:

• Fewer interventions
• Lower dosage of drugs
• Reduced period on ventilators
• Better communication between doctors and families regarding the aim of the treatment
• Reduced period of time before mobility is encouraged
• Pro-active psychological support

Advances in medical care have increased the lifespan of people, even patients admitted with severe medical complications that include patients suffering from certain forms of cancer, old and frail patients, patients with severe sepsis and cardiac patients. The post-ICU quality of life led by these patients, however, is compromised. Active monitoring of treatment mediated to patients and a practical assessment of their need and their ability to endure the treatment will aid in improving the lifespan of patients with a focus on the quality of their life.

References:

1. Exploring the scope of post-intensive care syndrome therapy and care
   http://www.ncbi.nlm.nih.gov/pubmed/25083984
2. My (critically ill) patient has only a pneumonia" - the risk of oversimplification and the evidence of post-ICU syndrome
   https://www.ncbi.nlm.nih.gov/pubmed/27008489
3. ICU Delirium: Information for Patients and Families
   http://www.icudelirium.org/patients.html
4. http://www.myicucare.org/Adult-Support/Pages/Post-intensive-Care-Syndrome.aspx
5. http://www.sccm.org/SiteCollectionDocuments/CC-Iwahyna-June-2013.pdf

Source-Medindia