Good afternoon, everybody. First and foremost, I'd like to thank the Society for inviting me to speak at this conference. In terms of my background, so I am, as he mentioned, I'm a medical ICU clinical specialist. I am also a clinical associate professor at Rutgers University. My practice site is at Rebel Wood Johnson University Hospital, and I've been there for quite some time, and I absolutely love it. And we recently started a PICS clinic there, but there's a lot to learn, so by no means am I an expert, but thank you for saying that. We're all learning about this particular syndrome as we are going along. So my learning objectives are essentially going to be starting out by describing the burden of unintended consequences in ICU survivors, and I will be identifying key features of this post-intensive care syndrome. Just of note, for the remainder of the talk, I will be referring this to as PICS. I will also provide some recommendations for prevention and management of PICS, and finally, I'll summarize some considerations for post-ICU care. Sorry. So what is PICS? So a little historical thing about how this term came about. So essentially, Dr. Dale Needham in 2012 held a stakeholder conference, which essentially focused on improving critical illness outcomes, long-term outcomes in our patients. And it was at this meeting that they came up with this definition, and PICS was defined as a new and or worsening impairment in physical, cognitive, or mental health status, which arose after a critical illness and persisted actually beyond their hospitalization. So that's the current definition. I will point out that there are many other domains of this particular syndrome as we're learning about PICS. But those are the three that I'm going to be focusing on today. How big of a problem is this? Well, we know that more than 5 million Americans are hospitalized in the ICU annually, and of those, about 4 million are discharged, whether it's home or skilled facility or wherever they end up at the end. But what we know is that these patients are not at their baseline. They are not the same people before their illness in the ICU started. Additionally, we know that when they're discharged, they're faced with a whole lot of problems as well. The exact prevalence of PICS among survivors is really unknown, but the data that is out there is basically saying that about a third of our patients that are critically ill where they have experienced ARDS or septic shock, they end up having this particular syndrome. And of course, along with the patients, their families also experience this syndrome. Studies have also shown that there are deficits in at least one PICS domain in 64% of our patients. And, wait a minute, it's happening. Can we go back? Sorry. One more slide, please. And then we know that 56% at 12 months with co-occurrence being common. So what you see here is a PICS model, and this model can actually be applied to patients that have survived ICU as well as their family members. So often we're always focused on the family members, but I do want to point out that the families that has a patient admitted or a family member that's admitted in the ICU also is experiencing this syndrome, and that's why it's referred to as a PICS-F, referring to the family. Family members also end up developing symptoms that are mental health-related symptoms such as anxiety, depression, PTSD, acute stress disorder. So we can't forget about these patients. In fact, I'll tell you, my mom was in the hospital last week and I experienced every single one of these symptoms. So we cannot forget about the family members. Now when we think about the patients, there are three main domains that are often talked about in the literature, and those are essentially your mental health, cognitive impairment, as well as physical impairment. As I mentioned earlier, by no means is this the limitations. There's many other impairments, as I said earlier, that the patients face. So just to talk a little bit about what are these impairments. So when we think about the mental health, we know that these patients are experiencing, similar to their family members, they experience anxiety, acute stress disorder, PTSD, depression, and so on and so forth. Whereas when we think about the cognitive domain, here these patients just don't think the same way as they used to prior to their hospitalization. They have a slowing of processing of information. In addition, they have memory loss, they have inattention, they just can't focus as well as they used to prior to their admission. And lastly, the physical impairment, again, these patients are weak. They have shortness of breath. They are in pain, they're in constant pain, even though their pain was managed, but then they end up having a lot of pain. In addition, they have impaired mobility as well. So how does PICC impact our patients? Well, we know that the PICC's associated impairments have a profound impact on our patients and their family lives. In fact, survivors of this particular syndrome, or survivors of the ICU rather, can end up going down the spiral road where they, and it's really because a third of these patients actually are not able to go back to work. Not because they don't want to work, they just physically are not able to go back to work. In addition, we know that a third of the patients do not go back to their pre-ICU job, nor do they ever end up with a pre-ICU salary that they were making prior to their illness. Needless to say that there is a substantial financial consequence for these patients and their family members, as well as there's economic implications for our society, as well as an increased healthcare utilization. I mean, it's sad that these patients cannot afford medications. They are not able to go to their outpatient clinic to follow up with their physicians. They're not able to even afford in-house healthcare. So it's a huge impact on our patients. The other thing is that some data suggests that patients that experience PICS actually end up having high risk for readmission to the hospital, as well as the ICU. So yesterday at the plenary session, one of the papers that were presented, he basically showed that these patients end up in the hospital earlier on, in fact, about 12 days earlier. So I mean, that just speaks volumes in my mind. So when we think about risk factors, so there's many different risk factors that are associated with each domain. So I'm going to just dive a little bit into the various risk factors. So when we think about the cognitive impairment, there was a landmark study that basically highlighted and taught us that patients that experience critical illness indeed have a long-term impairment in critical illness. As well as the study basically showed that, and the patients that were in this study, they experienced severe illness where they had ARDS, where they has septic shock. These patients, the study basically showed that these patients had a higher risk of higher cognitive scores, and this is because they had a higher duration of delirium. So this is nothing new. We've known this. Now we're just learning more about it, and hopefully in the future we'll be doing some more things about this. So listed here are some of the risk factors. By no means is this a comprehensive list, and there's multiple risk factors. We also do need to consider the patient's pre-existing illness prior to coming into the ICU. So before we list things that we need to think about is obviously advanced age is going to be a risk factor for cognitive impairment, as well as acute brain dysfunctions such as stroke, alcoholism, previous cognitive impairment. Additionally during illness, so while they're in the ICU, there's certain risk factors that are present as well. So presence of delirium, and then the other thing is how long were they in delirium. So duration of delirium is a huge risk factor, just as I mentioned in the previous study, in the brain ICU study published in 2013. The type of sedation that was used, and was it benzos, non-benzos, the dosing, and the duration of it. In addition, there was glucose dysregulation has deemed to be a risk factor as well, hypoxemia, patients that required longer duration of mechanical ventilation, sepsis, use of RRT, renal replacement therapy, as well as prolonged immobilization. Listed here are the risk factors for the mental health domain. So again, keeping in mind, we have the same risk factors as the cognitive impairments. In addition to that, we have again, we need to consider the prior critical illness considerations, things like pre-existing mental health problems, depression, anxiety, PTSD, and unfortunately female gender was also deemed to be a risk factor. And then during illness, while they're in the ICU, memories, patients that had memories experiences in the ICU. As well as again, sedation, it keeps coming back to sedation and analgesia, how long were they on it? Was it benzos? So these are all risk factors for mental health impairment. And then the last domain, the physical function domain, again, consideration of before critical illness, what was their pre-existing functional disability? How bad was it? And then during critical illness, again, how long were these patients on a mechanical ventilator? So we know that patients that were on a ventilator for more than seven days, use of steroids, use of paralytics, patients that had severe illness, this is all, we know that these are associated with ICU acquired neuromuscular weakness. So since it's such a big problem, why is it that it's missed? I think we all know that there's a generalized lack of awareness. Until we started talking about having a PICS clinic, I didn't know what PICS was. So I think people just don't know about this syndrome and then they don't know that it's fairly common as well. When we think about ICU discharging, plan is primarily focused on organ specific issues versus their functional impairment. Lack of best practices guidelines of diagnosis and treatment of PICS really are lacking. We also know that there's lack of knowledge among primary care physicians as well as outpatient physicians. They don't really know what exactly happens to these patients and the severity of their illness. I mean, we have some tools to use to assess and diagnose this, but we don't have validated scales or universal scales to help us assess PICS. So listed here is basically a compilation of the three different domains that I talked about and the common symptoms that these patients can experience, as I mentioned. So I'm not going to belabor this point since I went over this already. All right, so is there anything we can do to help mitigate PICS? Well, I think there are some things that we can definitely try to do better and one of them is certainly application of the ABCDEF bundle in our ICUs. I think there's one study that showed that it definitely does help with PICS, but we know that we can try and prevent a lot of these cognitive related issues when we implement these bundles in our ICUs. So I'm sure we're all familiar with this assessment and prevention and management of pain, making sure we're using validated tools to assess delirium pain, sedation, RAS, KMICU, et cetera. We know that early mobility has been shown to have an impact on our patients. Even with the duration of delirium, we all know that it's a known fact. And family engagement, oh my God, I think that's huge. So I think implementing and applying this bundle definitely can help our patients with the severity of the sickle eyes that they can experience. I think educating our survivors as well as their family members can be of huge importance as well. And then proactively assessing for PICS to identify impairment is going to be helpful as well. Of course, I'm a pharmacist, so I cannot finish this talk talking about preventing polypharmacy as well as making sure that medication reconciliation is conducted at every level of transitions of care, as well as optimizing medications and discontinuing unnecessary medications that our patients don't need. I think careful discharge planning is also very important. In fact, there's a recommendation in the consensus paper that came out in 2020 that talked about approaching to functional assessment. I think it's really important that providers assess and document pre-ICU functional abilities of our patients and put this in the chart. And it should serve as a great tool when the patient is transitioning from the ICU to other floors so that the other providers that are going to take care of this patient will know about where was this patient, where are they now, and what do we need to do to get them to their baseline or close to their baseline status. So listed here are just some of the post-ICU considerations. Again, we want to make sure that we screen for weakness after ICU discharge and refer them to physical rehabilitation when appropriate. We want to make sure that we're screening for cognitive impairment after ICU discharge, assessing our patients for depression, anxiety, and so on and so forth. And then certainly not to forget about the patient's family members, similar to our patients. They need to be assessed for these things as well. Excuse me. So what are some of the management strategies? Well, I think we're all familiar, we can all agree that post-ICU clinics definitely can have a role. And these are commonly multidisciplinary teams in the clinic that have been developed to address the broad spectrum of unmet needs for our critically ill patients that survive the ICU. We can certainly have various components included in this clinic. So assessment of their cognitive, the three core domains that I talked about. Certainly doing a thorough evaluation of their medications. We can also hook them up to a speech therapist, a dietician, rehab services, and so on and so forth. We think the ICU recovery clinics or post-ICU recovery clinics may help us with the reduction of hospital admission and reduce time to hospital admissions. Sorry, I'm not moving the slides, they're moving on, they have a mind of their own. We also know that, oh, the other thing I wanna say is I think the clinics can actually help providers really understand what these patients go through and then maybe improve our ways of the way things that we do in the ICU to help mitigate this as well. And then again, peer-to-peer support groups have definitely been deemed to be helpful and they can be conducted either via the phone, in person, or via the internet. Cannot finish my talk without just a word about COVID, but I know Dr. Nessie's gonna be talking a little bit more about this. So we know that patients with COVID are going to be indeed at risk for developing this syndrome. The management of COVID after ICU is still evolving. I will say that there was a recent observational study that was published that showed that five patients, one out of five patients hospitalized with COVID had no primary care follow-up within 60 days of their discharge. So I think hopefully we can do a better job with that in the future. So really the key takeaways are really preventing recognition in management of PICS has come to the forefront of critical care. PICS definitely is associated with a range of important problems confronting survivors and their families. We're hoping ICU recovery clinics can help our patients. And we know that the impact in various aspects of ICU care remains unknown. And this is, this is and should be a priority for our critical care community. With that, I thank you.

medical ICU

post-intensive care syndrome

PICS

unintended consequences

ICU survivors