Post-Intensive Care Syndrome (PICS)
Post-Intensive Care Syndrome (PICS) is a neurologically heterogeneous complex of impairments characterized by new or worsening physical, cognitive, and/or psychological functions that persist beyond ICU and hospital discharge, affecting up to 64% of ICU survivors. 1
Definition and Domains
PICS encompasses three primary domains of impairment:
1. Physical Impairments
- Often referred to as "Intensive Care Unit-Acquired Weakness" (ICU-AW)
- Includes neuromuscular dysfunction affecting:
- Swallowing
- Breathing
- Mobility
- Personal autonomy 1
- Severe axonal critical care neuropathies can result in prolonged convalescence and incomplete recovery
- Affects 25-40% of patients at discharge 1
2. Cognitive Impairments
- Manifests as:
- Delirium
- Deficits in attention
- Memory problems
- Executive function impairment
- Visuospatial perception difficulties 1
- Affects 25-40% of ICU survivors at 3 months post-discharge 1
3. Psychological Impairments
- Includes:
- Depression (32% at 12 months)
- Anxiety disorders (38% at 12 months)
- Post-traumatic stress disorder (18% at 12 months) 1
Prevalence and Timeline
- 64% of ICU survivors show impairment in at least one domain at 3 months
- 56% show impairment at 12 months
- 25% have impairments in two domains at 3 months
- 21% have impairments in two domains at 12 months
- 6% have impairments in all three domains at 3 months
- 4% have impairments in all three domains at 12 months 1
- Symptoms may appear as early as 24 hours after ICU admission
- Effects can persist for 5-15 years after discharge 1
Risk Factors
PICS development is multifactorial with risk factors occurring at different stages:
Pre-ICU Risk Factors
- Frailty
- Pre-existing functional impairments 1
During ICU Stay Risk Factors
- Sedation
- Duration of delirium
- Sepsis
- Acute respiratory distress syndrome 1
Post-ICU Risk Factors
- Early symptoms of anxiety
- Depression
- Post-traumatic stress disorder 1
Impact on Family (PICS-F)
- Family members can also be affected by the ICU experience
- Creates a complex, interacting phenomenon between patient and family recovery 1, 2
- Includes mental health consequences for families and caregivers of ICU survivors 2
Assessment and Management
Regular assessment is crucial for early detection and management:
- Assessment should occur throughout the continuum of care: during ICU stay, acute inpatient care, rehabilitative inpatient care, and outpatient care 1
- Rehabilitation requires a multidisciplinary approach involving specialized doctors, nurses, and therapists 1
- Preventive strategies include the ABCDEFGH bundle (delirium prevention, early rehabilitation, family intervention, and follow-up) 3
- ICU diaries have shown benefit in managing psychological aspects 1
Clinical Implications
- PICS significantly impacts quality of life and participation in society
- Leads to increased morbidity, rehospitalization, and mortality 1
- Creates substantial socioeconomic burden 4
- Requires continuity of care similar to stroke rehabilitation pathways 1
Common Pitfalls in PICS Management
- Fragmented care for critical illness survivors 1
- Underdiagnosis due to symptoms emerging at different phases of recovery 1
- Failure to distinguish between impairments related to primary brain injury and those resulting from critical care in neurocritical patients 2
- Overlooking the impact on family members and caregivers 2
PICS represents a significant challenge in critical care medicine, requiring systematic assessment and multidisciplinary rehabilitation to improve long-term outcomes for ICU survivors.