What is the best approach to manage a patient with chronic critical illness, including optimization of physical and cognitive function, and treatment of common comorbidities such as depression, anxiety, and neuropathic pain?

Management of Chronic Critical Illness

Implement multimodal rehabilitation targeting physical, cognitive, and psychological domains starting in the ICU and continuing through all phases of recovery, with early mobilization, delirium prevention, ICU diaries, and psychological interventions as core interventions. 1

Core Rehabilitation Framework

The management of chronic critical illness requires addressing three interconnected domains that define Post-Intensive Care Syndrome (PICS): physical impairments, cognitive dysfunction, and psychological sequelae. 1 These symptoms can emerge as early as 24-48 hours after ICU admission and persist for 5-15 years after discharge, affecting 64% of ICU survivors at 3 months and 56% at 12 months. 1

Physical Rehabilitation

Early mobilization should be implemented as soon as medically feasible, progressing from sitting at the edge of the bed to walking with therapist assistance. 1 This intervention carries a Grade A recommendation with moderate-to-high quality evidence showing:

• Significant reduction in delirium incidence 1
• Decreased mortality rates 1
• Prevention or reduction of PICS symptoms 1

Physical therapy protocols should include:

• Strength training with optimized frequency and duration 1
• Device-assisted therapy (wheelchair cycle ergometers, electrical stimulation) for specific subgroups 1
• Speech-language therapy for swallowing dysfunction, tracheostomy management, and coordination of respiration/swallowing/coughing 1
• Therapist-driven weaning protocols with daily spontaneous breathing trials through tracheostomy collar for ventilator-dependent patients 1, 2

Cognitive Rehabilitation

Screen repeatedly for cognitive impairments throughout the illness trajectory, as 25-40% of ICU survivors experience cognitive dysfunction at 3 months. 1 While specific cognitive therapy interventions lack strong evidence, the guideline emphasizes:

• Repeated screening using validated assessment tools 1
• Orientation aids and communication improvement strategies 1
• Environmental modifications (noise reduction, ear plugs, eye shields, light management) 1

Psychological Management

Psychological interventions should be offered in the ICU and early rehabilitation to patients and family members for anxiety, depression, and PTSD. 1 The evidence supports:

ICU diaries (Grade A recommendation): Written by nurses, therapists, or family members documenting events, visits, and patient progress with photographs and psychoeducational information to reduce anxiety, depression, and PTSD symptoms. 1

Professional psychological support: Access to follow-up care targeting psychological stabilization should be offered in the first 12 months after discharge. 1 Resilience training reduces anxiety and depression with effects stable over 12 weeks. 1

Depression prevalence reaches 32% at 12 months, anxiety 38%, and PTSD 18%. 1 Treatment should include:

• Tricyclic antidepressants or selective serotonin reuptake inhibitors 3, 4
• Psychosocial interventions 3, 4
• Multidisciplinary approach including mobilization, communication facilitation, information provision, and resilience training 1

Delirium Prevention and Management

Implement multimodal delirium prevention strategies (Grade A recommendation) as delirium increases the probability of developing PICS. 1 Evidence-based interventions include:

• Early mobilization (sitting to walking based on patient abilities) 1
• Contact with family members 1
• Cognitive programs (orientation aids, communication improvement) 1
• Environmental modification (noise reduction, ear plugs, eye shields, light management) 1
• Multimodal interventions addressing concurrent symptoms and stress reduction 1

Do NOT use prophylactic haloperidol for ventilated patients (Grade B recommendation against), as it shows no effect on delirium incidence, severity, duration, or outcome compared to placebo. 1

Pain and Sedation Management

Prioritize analgesia-first sedation strategies (analgosedation) targeting light sedation when possible, using short-acting agents and avoiding benzodiazepines. 1 This approach allows patients to be more awake and able to participate in early mobilization and family interactions. 1

• Assess pain regularly using standardized validated tools 1, 3
• Use opioids as primary analgesic for severe pain, with morphine requiring careful titration 3
• Implement daily sedation interruptions paired with spontaneous breathing trials 1
• Avoid deep sedation practices that prolong recovery and increase complications 1

Neuropathic Pain Management

For neuropathic pain commonly seen in chronic critical illness:

Pregabalin is FDA-approved for diabetic peripheral neuropathic pain and fibromyalgia in adults. 5 Common dose-related adverse effects include dizziness (26-32%), somnolence (16-22%), peripheral edema (5%), and weight gain (12%). 5

Duloxetine is FDA-approved for diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain in adults. 6

Palliative Care Integration

Palliative care should run parallel to life-sustaining treatments from day one, not represent a transition away from critical care. 7 Intensify palliative care discussions when:

• Mortality risk exceeds 40-60% despite maximal therapy 7
• Functional decline is documented and progressive despite aggressive interventions 7
• Patient meets terminal criteria for hospice 7

Essential palliative care competencies include:

• Prognosticating survival and expected quality of life 7
• Managing withholding and withdrawing life-sustaining therapy 7
• Pain and dyspnea symptom management using established protocols 7

Systematically assess and aggressively treat pain, dyspnea, and depression at regular intervals. 7, 4 For dyspnea, use opioids appropriately titrated without unfounded fears about respiratory depression. 7

Advance Care Planning

Ensure advance care planning occurs for all patients with serious illness, addressing:

• Surrogate decision makers 3, 4
• Resuscitation preferences (DNR orders) 3
• Emergency treatment preferences 3
• Goals of care discussions early when prognosis is potentially poor 3

Reassess care plans when significant clinical changes occur. 4

Multidisciplinary Team Approach and Care Coordination

A multidisciplinary team approach improves quality of life, functional status, and reduces hospital readmissions and costs. 3, 4 The team should include:

• Specialized physicians, nurses, and therapists from various disciplines 1
• Coordination between primary physicians and specialists 4
• Nurse case management 4
• Patient and family activation 4

PICS rehabilitation should occur across multiple healthcare settings: ICU, acute rehabilitation unit, post-acute rehabilitation unit, outpatient clinic, community-based, and domiciliary settings. 1

Family and Caregiver Support

Screen adult caregivers routinely for practical and emotional needs. 3, 4 Provide:

• Listening to concerns and attention to grief 3
• Regular information updates about patient condition 3
• Encouragement for family presence with the patient 3
• Bereavement services extending up to one year after patient death 4
• Support for professional caregivers given the emotional toll 7

Common Pitfalls to Avoid

Do not delay palliative care consultation until end-of-life, as this negatively impacts patient outcomes. 4 Early palliative care consultation improves both quality and duration of life. 4

Avoid undertreatment of dyspnea due to concerns about respiratory depression from opioids—appropriate dosing is safe and effective. 3, 7, 4

Do not fail to complete advance care planning early in the course of serious illness, as this leads to inadequate end-of-life care. 4

Avoid deep sedation practices that were mistakenly adopted during the COVID-19 pandemic—return to light sedation targets and analgosedation strategies. 1

Comorbidity Management

Identify and definitively treat all comorbid conditions including PTSD, depression, and diabetes, as proper treatment improves symptoms, reduces complications, and clarifies residual symptoms attributable to chronic critical illness. 1