giving the talk entitled Post-ICU Syndrome, What Is It, and Why Does It Matter? For this talk, I have no disclosures. Post-intensive care syndrome, or PICS, is made up of health problems that remain after critical illness. PICS is present in the patient in the intensive care unit, may persist after the patient returns home. Health problems can involve the patient's body, thoughts, feelings, or mind, and may affect the family. PICS may show up as an easily noticed, drawn-out muscle weakness, known as ICU-acquired weakness, as problems with thinking and judgment, as well, called cognitive brain dysfunction, and as other mental health problems. Regarding ICU-acquired weakness, it is a muscle weakness that develops during ICU stay. It is a common problem of critical illness that occurs in 33% of patients who are on ventilators, 50% of all patients admitted with sepsis, the 50% of patients who remain in the ICU for at least one week. And patients who develop ICU-acquired weakness may take more than one year to fully recover. ICU-acquired weakness makes daily living activities difficult, including grooming, dressing, feeding, bathing, and walking. In addition, it may greatly delay the patient from doing activities in the way he or she is used to doing them. Regarding cognitive or brain dysfunction, this refers to problems associated with remembering, paying attention, solving problems, or doing other things such as organizing and working on things such as complex tasks. After leaving the ICU, 30 to 80% of patients may have these problems. Some people improve during the first year after discharge from the hospital. However, others may never fully recover. Cognitive dysfunction may affect the patient's ability to work, balance a checkbook, or perform other tasks that involve organization and concentration. Other mental health problems can occur as well. Patients may develop problems with falling and staying asleep. They may have nightmares and unwanted memories. They may have reminders of their illness that, or reminders of their illness may produce intense feelings of strong, clear images in their minds that are unwarranted and unwanted. Their reactions to these feelings may be physical or emotional. Patients may feel depressed, anxious, and have symptoms of post-traumatic stress disorder. And these can include nightmares or unwanted memories, feeling keyed up, and avoiding thinking or talking about their stay in the ICU. How does post-PICS affect recovery? Up to 50% of patients may return to work within the first year, but some may not be able to return to the jobs they had or their illness. Patients may need sleep, may need help with daily activities after leaving the hospital as well. So you can start getting an idea of how devastating PICS can be to the individual. Here is some work that was published in Critical Care Medicine. This diagram illustrates the co-occurrence of PICS problems at three and 12 months. As you can see, you have an A and B panel with the circles of depression, cognitive impairment, and disability. The proportion of patients with PICS problems in each domain at three months is presented in the A box, while 12 months is at B. As you can see, cognitive impairment is represented in the red circle, disability and activities of daily living are the yellow circle, and depression by the blue circle. The overlap of the circles represents the co-occurrence of two or three problems. Overall in this paper, they demonstrated six out of the 10 patient had PICS. The most common pattern at both three and 12 months was problems in a single domain. However, it was present in four out of 10 patients. Co-occurring problems in two or three domains is present in two of the 10 patients. What about things such as been recently when we had coronavirus? Recent paper published in critical care explorations by our society. One, this was done by Banno et al. You look at one year outcomes of post-intensive care syndrome and critically ill corona disease patients in 2019 from a single institution. They basically were able to conclude that patients who suffered critical illness from coronavirus had a high frequency of PICS after one year and long-term follow-up care should be continuously offered. So you can see that this is something that's with us and will continue to be with us for quite a while. Now I'd like to talk a little bit about PICS specifically after sepsis and surgery in a project that we did at the University of Florida. Now we specifically wanted to look at the chronically critically ill patient population who are at higher risk of PICS. There are multiple definitions of chronic critical illness in the literature. We specifically defined it as greater than 14 days of intensive care resource utilization with the patient being in the ICU with persistent organ dysfunction. And these patients, these chronic critical ill patients continue to increase in number as well as in cost in the United States. So our objective in this study was to determine the current epidemiology of surgical sepsis and to compare traditional inpatient outcomes to long-term functional outcomes in mortality of sickly patients treated for sepsis. Study methods were as it was perspective study of surgical ICU patients treated for sepsis. We determined their baseline characteristics. We examined inpatient clinical outcomes and we looked at one year longitudinal follow-up, three, six, and 12 months. We also studied their clinical trajectory. At this point in the study, we had 301 patients. We defined early deaths as patients who died before 14 days which for a surgical sepsis unit was surprisingly low at 4%. About two thirds of the remaining patients had what we've defined as a rapid recovery. And they left the ICU within 14 days. The other third met the criteria for chronic critical illness. If you divide these patients up between rapid recovery and chronic critical illness, see that those that were chronic critically ill were more likely to be male, had an older age, which is not surprising, a higher Charleston comorbidity ectecs and Apache two score, which again, not surprising. And also not surprisingly, were more likely to have been in septic shock. Those are chronic critical illness, had more ICU days, hospital days, were more likely to have secondary infections, more likely to have had acute kidney injury and higher Kodigo scores, more likely to have multiple organ failure. And they also had a higher, a greater percentage of 30 day mortality. Now, if we look at their post discharge disposition, now that we understand that it's not always about early mortality, 28 day mortality, we considered a good disposition. Those patients that went home into rehabilitation, we considered a poor disposition. Those patients that went to an LTAC or a SNF, knowing that often these patients don't do well, transfer back to their original hospital, hospice or first hospital deaths. And we found that the patients who had rapid recovery or had a 79% chance of a good disposition or a 21% chance for poor disposition while chronic critical ill patients had an 18% chance of a good disposition or those that had a poor disposition, 82% chance of having a poor disposition. We also evaluated these patients using the Zubride score, a score that was valid, been validated for years now by cancer study groups. This is numbered from zero to five with zero being patients being asymptomatic, being fully active, going all the way to four with severe disability, completely disabled and five being deaf. As you can see, overall patients after sepsis are somewhere between the mild and moderate disability score but if you divide it by rapid chronic critical illness, rapid recovery are likely to be between mild disability and highly functional. While chronic critical illness patients are between moderate and severe disability all the way out to one year. Other tests that we ran included short performance, physical performance batteries. You can see we're worse in chronic critical illness. Hopkins verbal learning test, which again was worse at 12 months in the chronic critical illness patients as well as the EQ5D3L utility index test was worse three, six and 12 months in the chronic critical illness patients. And then if you look at one year mortality, you can see that there's a significant difference at 30 and one year mortality with rapid recovery being zero at 30 days and 16% of chronic critical illness but more importantly at one year out being 5% and 41% for rapid recovery chronic critical illness respectively at one year. So summary, traditional 30 day mortality is notably low in surgical sepsis, early deaths were 14 days from refractory shock and multi-organ failure was less than 5%, greater than 60% of patients with surgical sepsis rapidly recover with mild disability. Every one third of these initial survivors develop chronic critical illness with severe disability do not recover and have a 40% one year mortality and meet as we defined the definition of PICS and sepsis recidivism and non-resolving multi-organ failure were determined to be leading causes of late deaths in these early sepsis survivors. The Society of Critical Care Medicine has had an international consensus conference on prediction identification of long-term impairments after critical illness. And they have come up with a recommended approach to functional assessments across the continuum of critical illness and recovery. This was again was published in CCM in 2022. It should start with the ICU admission where you assess pre-ICU functional abilities and document this in the history of physical. You should continue to work with documentation as the ICU if the patient ends going to the floor with a handoff with a report of pre-ICU functional abilities assessment and current functional abilities achieved. As the patient achieves a hospital discharge, you conduct pre-discharge functional assessment, functional reconciliation linked to pre-ICU abilities to guide post-acute referral and post-discharge screen at risk patients using recommended tools, conduct initial post-discharge screening within two to four weeks of possible discharge. I hope that this talk has been helpful in making you understand how important the PICS syndrome is and the SCCM's leadership and getting this out to the community and what it is and how important it is that people understand that this phenomenon exists in our patients. And the further talks that will occur in this session, we'll talk more about what interventions can be done and how we can help our patients recover better from this awful syndrome. Thank you.

Post-intensive care syndrome

PICS

muscle weakness

cognitive dysfunction

mental health issues