Post-intensive care syndrome (PICS) – prevention and treatment

INTRODUCTION

Post-intensive care syndrome (PICS) is a common phenomenon following hospitalisation in the intensive care unit (ICU) [1], and therefore the treatment team should strive to identify patients at risk of developing mental, physical, or cognitive disorders as early as at the time of admission [2].
Precise PICS incidence rates are not clear because existing reports reveal varying ranges. It is estimated that patients experience new mental (8-57%), physical (25-80%), or cognitive (30-80%) impairments after their stay in the ICU [2]. The health consequences of PICS can have a long-term impact on the patients’ and their caregivers’ functioning. Families of critically ill patients are exposed to stressful situations, which may result in them experiencing a phenomenon defined as post-intensive care syndrome in the family (PICS-F) [3]. Many risk factors of PICS have been identified. The occurrence of delirium contributes to the development of long-term cognitive disorders. The other risk factors include severity of the underlying condition, prolonged mechanical ventilation, and the occurrence of sepsis during the stay [2, 3]. These factors significantly influence the development of disorders in the physical, mental, and cognitive spheres [3]. Medical staff should be aware that other factors for the development of PICS are also possible [4].
The multifactorial and multidimensional nature of PICS syndrome causes difficulties in treatment, which is why the importance of preventive measures and its early recognition is emphasised [3, 4]. These measures include rehabilitation, occupational therapy, cognitive therapy, keeping ICU diaries, referring the patient to rehabilitation clinics [5], and following procedures and recommendations.
The aim of this study was to present prevention and treatment methods for patients diagnosed with post-intensive care syndrome. The paper was based on the literature analysis in the following databases: Cochrane Library, PubMed, and Medline.

INTERVENTIONS AND PROCEDURES TO PREVENT PICS

Advances in ICU care are related to the development of interventions and procedures that reduce the long-term effects of hospitalisation; initially, a package of interventions contained in the acronym A-F. Current management guidelines suggest implementation of additional interventions and expand the acronym with the letters G (learning about the patient’s habits and lifestyle before hospitalisation), H (use of different forms of therapy increases the effectiveness of multimodal treatment), and I (increase feelings of security and comfort by using private objects) [6] to prevent delirium and prolonged immobilisation [4, 6, 7]. The letter meanings indicate the areas of interventions undertaken.
Following the A-I guidelines, or combining them with additional tools, can triple the number of patients returning to independent functioning after ICU discharge (Fig. 1) [4]. By conducting interventions in various areas that are closely related to each other, it is possible to ensure the patient’s well-being in cognitive, mental, and physical spheres [6]. Table 1 provides a detailed reference to the above areas [2-4, 6-25].
The undertaken interventions require close interdisciplinary cooperation within professional competences. The nurse, as an active member of the therapeutic team, performs interventions to ensure the patient’s psycho-physical wellbeing, which can be included in areas A-I (Table 2) [3, 4, 6-8, 10-19, 22, 24, 26, 27].
Prevention of PICS syndrome must include analysis of environmental factors in the ICU, which include continuous exposure to noise, and improper lighting and temperature [19, 28]. There are no World Health Organisation (WHO) recommendations for hospital lighting. Patients in the ICU are exposed to artificial light at night and low lighting during the day. It is important to maintain diurnal variation in lighting by remotely controlling lighting and its temperature [29]. Artificial light disrupts the “sleep-wake” balance [30], due to reduced melatonin levels, particularly noticeable in patients who have a bed close to an artificial light source [30-32]. Limiting exposure to artificial light promotes prevention and treatment of delirium. When light exposure is limited or constant, biological rhythms can become desynchronised [30, 31].
An optimal temperature is 18-22°C, while humidity is 40-60%. Temperature in the ICU is top-down monitored, and the patients are often unable to adjust their microenvironment on their own, such as by uncovering or covering themselves with bedding. Incorrect temperature and humidity reduce sleep quality [33].
The WHO recommends that noise should not exceed 35 dB, but these guidelines are difficult to achieve [29]. The ICU equipment with safety alarms allows the treatment team to respond in cases of potential danger to the patient. However, sounds from infusion pumps, vital signs monitors, and ventilators, combined with sounds from phones and staff conversations with patients and their families, increase patients’ stress levels [28]. In addition, noise from treatment interventions and conversations reduces the quality of nighttime sleep [7, 29, 33], prolonging ICU stays and requiring pharmacological measures [29]. Exposure to noise is associated with increases in cortisol levels, blood pressure, and pain sensation. Exposure to music during the ICU stay, on the other hand, can reduce levels of perceived pain while affecting cardiovascular parameters [28], reducing feelings of anxiety, as does the use of noise-cancelling headphones [7].
Several tools have been developed to identify symptoms indicative of developing PICS in terms of physical, mental, and cognitive dysfunction, and quality of life [34] (Table 3) [35-48]. The heterogeneous nature of PICS required the development of a tool that takes into account all aspects of post-intensive care syndrome. The Post-Intensive Care Syndrome questionnaire (PICSq) and the Health Aging Brain Care Monitor (HABC – M) are screening tests designed to comprehensively examine symptoms indicative of PICS development (Table 4) [49-51]. In the treatment of psychiatric symptoms, psychotherapy can be a beneficial therapy choice [34]. The multidisciplinary nature of a treatment team is underscored by the presence of psychologists who help reduce the feelings of stress among patients and their relatives. Daily intervention by psychologists should address the experience of stress, sleep disorders, anxiety, delirium, and coping styles of both the patient and family [6, 52]. Supporting the work of psychologists by the ICU nursing team provides better results in the treatment of pain and anxiety and improves the quality of patients’ sleep [52].
Intensive care unit patient diaries can be created with the participation of therapists, nurses, or family members to record events that the patient was unable to remember due to a critical medical condition. Their use reduces the risk of anxiety, depressive symptoms, and post-traumatic stress disorder (PTSD) [18]. Although there is no universal template for their creation, their importance for patients diagnosed with cognitive disorders is emphasised [34]. Reading diaries enhanced with photos after hospitalisation fills in memory gaps and facilitates understanding of events (e.g. medical conditions, family visits, medical procedures) [7]. There is no clear evidence of the importance of diaries for delusional and traumatised patients [53].
Occupational therapies are used to treat cognitive impairment and overcome difficulties that have developed during the ICU stay [54].
Patients and their relatives attending support groups have confirmed a reduction in feelings of loneliness and an increased sense of support in coping with ailments after an ICU stay (PICS) [5].
Studies emphasise that pharmacotherapy should be used for behavioural disorders present [21] and psychotic symptoms [36].

PICS MONITORING AFTER ICU STAY

Every patient, upon discharge from the ICU, should undergo psychological evaluation and observation to assess physical, mental, and cognitive functioning [19, 25]. Institutions dedicated to patients discharged from the ICU are follow-up clinics. Their task is to assess the risk of developing, treating, and preventing PICS [7, 34, 54]. These clinics are an important link in the professional care of patients after an ICU stay. They provide education, support, and counselling to patients and family in the areas of nutrition, rehabilitation, and sleep hygiene, among others [4]. The study of the impact of “follow-up” programs also does not fully confirm their effectiveness [55].
Some studies indicate that in the treatment of mental disorders among patients residing in their own environment, the use of mobile applications shows promising results. Interventions carried out with their help reduce psychological tension among patients and their families, increase satisfaction with care, and at the same time reduce the cost of care [10].
Patients can also expect professional help from their primary care physician (PCP), especially to monitor pharmacotherapy and its side effects [34]. As a part of the primary healthcare, patients can also benefit from the assistance of a nurse in the form of inpatient as well as home care. It is then required to have insurance with the Social Security Administration (ZUS) [56].
The Polish healthcare organisation does not have institutions in the form of follow-up clinics, but there are professional centres for long-term care and support for patients after a critical illness (Fig. 2).
Patients who do not require treatment in the ICU but require care are most often qualified for long-term care in the form of inpatient or home care. These forms of care are provided in both the public and private sectors, providing round-the-clock, holistic care for dependents following serious or chronic illness [57]. Public sector services in care and medical facilities (ZOL) and nursing and care facilities (ZPO) are 70% paid for by the patient, while 30% of the cost is borne by the National Health Fund (NFZ). These centres provide round-the-clock care for dependent patients. The period of stay depends on the patient’s Barthel scale score and health status [56]. Therapeutic rehabilitation after a stay in the ICU is possible in the form of day rehabilitation centres or a stay in a rehabilitation ward, upon referral by a specialist. Severe disabilities allow access to rehabilitation outside the waiting queue [56].
For social assistance support, it is necessary to contact the nearest municipality or city office, where social assistance centres are located. They offer care support and specialised support provided by people with specialised training [56].
Given the lack of dedicated facilities in Poland for patients struggling with PICS syndrome, it is difficult to clearly determine whether the care guaranteed there is sufficient for the patients’ needs and problems after hospitalisation in the ICU. Therefore, it is very important for informed professionals to undertake all interventions aimed at preventing the development of PICS and to enlist the cooperation of the patient’s immediate environment through well-conducted education.

SUMMARY

Interventions undertaken in the ICU to reduce the risk of PICS should result from a proper assessment of the patient’s condition dictated by focused observation [14, 49, 58]. The guidelines do not provide a “golden mean” to alleviate the PICS symptoms but emphasise the importance of cooperation among healthcare providers [22]. The future of effective ICUs lies on a foundation of collaboration between physicians, physiotherapists, nurses, psychologists, speech therapists, clinical pharmacists, dieticians, occupational therapists, social workers, and spiritual guides –depending on religion. Consequently, all the patient’s needs will be met [6]. In addition, the important role of communication between the treatment team and patients and their families is emphasised in the effective functioning of the ICU [14, 49, 58]. It is also important to develop guidelines and screening tools that take into account the multidimensionality of PICS [49].

CONCLUSIONS

PICS prevention should be implemented at the time of the patient’s admission to the ICU and should result from an assessment of individual patient needs identified through various techniques and methods of health assessment and risk factor reduction.
Treatment of PICS requires a multidisciplinary approach – pharmacological, psychological, and physiotherapeutic interventions – that do not always guarantee the patient’s return to full functionality and independence.
The lack of facilities in the healthcare system providing health services to people with post-intensive care syndrome should sensitise professionals to the prevention, early detection, and treatment of PICS.

Disclosures

This research received no external funding.
Institutional review board statement: Not applicable.
The authors declare no conflict of interest.

References