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Post-Intensive Care Syndrome

title: PICS - Post Intensive Care Syndrome tags: notebook: 🌑-FFICM

Life After Critical Illness

In 2020 - 75% of ICUs responding to a survey reported having some form of ICU recovery clinic service. 73% of all UK ICUs responded to survey (100% of scottish ICUs)

Split the post ICU limitations into:

  1. Physical
  2. Cognitive
  3. Psychosocial

Critical Illness is also a family crisis

Critical Care Rehabilitation is one of the SICSAG Quality Indicators

It's also in GPICS

In the first year after hospital discharge following critical illness : - over half of ICU survivors visit an emergency department - a third are readmitted within 30 days of hospital discharge - up to 60% are readmitted within a year - Unemployment rates of previously employed intensive care unit survivors are high with: - 2/3 unemployed at three months - 2/5 at 12 months - 1/3 at 60 months are jobless following hospital discharge

Handover From ICU To Ward

Recommendations from NICE:

  • a summary of the critical care stay, including diagnosis and treatment
  • a monitoring and investigation plan
  • a plan for ongoing treatment, including medications (see section 3.8) and therapies, psychology sessions,
  • if necessary, nutrition plan, infection status and any agreed limitations of treatment
  • an agreed individualised structured rehabilitation programme, including:
  • physical,
  • psychological,
  • emotional
  • and cognitive needs
  • specific communication or language needs.

Assessment and Screening Tools

  • Physical:
    • Chelsea Critical Care physical assessment tool
  • Cognitive:
    • CAM-ICU
    • 4AT
    • Abreviated Mental Test Score
  • Psychosocial:
    • Intensive Care Psychological Assessment Tool (IPAT):
      • Good for detecting distress, not validated for PTSD

Readmission Risk

  • SCARF Tool:
    • Supporting Community Recovery + Reducing Readmission Risk following critical illness
  • Risk Factors:
    • Comorbidity - 4 different morbidities before admission to ICU
    • Live Alone
    • Polypharmacy - 4 or more prescribed medications before ICU
    • Pre-existing Mental-health problems
    • Pre-existing mobility problems

Outpatient Clinics

Who should attend?

Starting point:

Mechanical Ventilation of 72hrs+ (3 Days) OR Length of Stay in Critical Care of 96hrs+ (4 Days)

When should they attend?

~ 2- 3 months after discharge from cricial care

How often should they attend?

Not often.

One follow up. Maybe one more after that. Rare circumstances a third appointment.

Shouldn't really be having more than 3, or attending after a year post discharge. At those points should be referred back into community support.

Critical Care Case Mix Metrics

  • Length of stay
  • Readmission
  • APACHE2 and SOFA score
  • Days mechanically ventilated
  • Reintubations
  • Tracheostomy Y/N
  • Grade of kidney injury
  • Days of renal replacement therapy
  • Advanced cardiovascular support (multiple inotropes, IABP, other mechanical)
  • ECMO Y/N
  • Surgeries and procedures
  • Infection status
  • Delirium Y/N/duration
  • Nutritional support
  • Comorbidities and mental health background

(These metrics would be useful for MD, to get from SICSAG for the cohort)

Clinic Outcome Measures

Uncertain which ones to use:

Physical: - EQ5D Cognitive: - MOCA-Blind Psychosocial: - HADS - IES-R - Patient Health Questionnaire / Generalised Anxiety Disorder Assessment / Trauma Screening Questionaire

PICS

Survivorship - People are generally called a "survivor" of ICU after getting out

Post Intensive Care Syndrome was defined in 2010 by the Society of Critical Care Medicine.

There was an aim to get expert consensus (including patients as experts as well as HCP)

They came up with Core Outcome Sets to follow up after intensive care

This was followed up in 2019

New or worsening problems in physical, cognitive or mental health arising after a critical illness. Persisting beyond acute hospitalisation. Can apply to survivor or family member

  • Mental health
  • anxiety
  • ptsd
  • depression
  • (complicated grief for family members)
  • Cognitive impairments
  • Executive Function
  • memory
  • attention
  • visuospatial
  • mental processeing
  • Physical impairments
  • Pulmonary
  • Neuromuscular
  • Physical Function

Can we predict who is likely to get it? Not really no.

There might be some stuff to follow up after ICU.

The Hospital Anxiety and Depression Score is the one system that consistently gets recommended by guidelines.

Generally if you've got cognitive/mental health/physical comorbidities before ICU you're more likely to have issues after.

Delirium is the most likely predictor of cognitive dysfunction after.

Maybe sedatives cause issues.

Generally the sicker you are the more likely to have cognitive dysfunction after.