Evaluation of the Impact of ABCDEF Bundle Compliance Rates on Postintensive Care Syndrome: A Secondary Analysis Study

Prehabilitation to mitigate postintensive care syndrome in surgical patients: The rationale for a peri-critical illness pathway involving anaesthesiologists and intensive care physicians

The post-intensive care syndrome (PICS) refers to the long-term physical, psychological and cognitive impairments experienced by intensive care unit (ICU) survivors, while PICS-Family (PICS-F) affects their family members. Despite preventive strategies during the ICU stay, PICS remains a significant concern impacting survivors' quality of life, increasing the healthcare costs, and complicating recovery. Prehabilitation offers a promising approach to mitigating PICS and PICS-F, especially when the ICU stay can be anticipated, such as in the case of major surgery. Recent literature indicates that prehabilitation - interventions designed to enhance patients' functional capacity before critical illness - may mitigate the risk and severity of PICS. Studies have demonstrated that prehabilitation programs can improve muscle strength, reduce anxiety levels and enhance overall quality of life in ICU survivors. Family prehabilitation (prehabilitation-F) is also introduced as a potential intervention to help families to cope with the stress of critical illness. This article aims to explore the role of multimodal prehabilitation and post-ICU follow-up in preventing and managing PICS and PICS-F, focusing on improving patient outcomes, supporting families and optimising healthcare resources. Combining prehabilitation with post-ICU follow-up in peri-critical care clinics could streamline resources and improve outcomes, creating a holistic care pathway. These clinics, focused on both pre-ICU and post-ICU care, would thus address PICS from multiple angles. However, the heterogeneity of patient populations and prehabilitation protocols present challenges in standardising the interventions. Further research is necessary to establish optimal prehabilitation strategies tailored to individual patient needs and to demonstrate their utility in terms of patient outcome.

Incidence and risk factors of Post-intensive care syndrome (PICS) in surgical ICU survivors: a prospective Chinese cohort study

BACKGROUND

Post-intensive care syndrome (PICS) is a term coined by the Society of Critical Care Medicine to describe the psychological, cognitive, and physical dysfunction that ICU survivors may experience. Although surgical patients represent a substantial proportion of ICU survivors, studies describing PICS in this specific population remain limited. This study aims to determine the incidence and independent risk factors associated with PICS among surgical ICU survivors in a Chinese cohort.

METHODS

The study was a prospective cohort study of critically ill surgical patients who were discharged from the ICU at the First Affiliated Hospital of Sun Yat-sen University between August 2021 and June 2022. Demographic characteristics, disease-related information, and ICU treatment were collected, and enrolled participants were followed up within six months after ICU discharge. The Chinese version of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) and the Short Memory Questionnaire (SMQ) were used to assess PICS. The physical component summary (PCS) and the mental component summary (MCS) were averaged from the corresponding four-dimension scores in the SF-36. PICS diagnosis was determined based on the presence of at least one of the following: physiological dysfunction (defined as PCS reductions greater than 10), psychological dysfunction (defined as MCS reductions greater than 10), or cognitive dysfunction (defined as SMQ reductions and scores less than 40 at six months). PICS diagnosis was based on the presence of at least one of the following: physiological, psychological, or cognitive dysfunction.

RESULTS

A total of 565 patients were screened in this study, and 83 were enrolled after applying the inclusion and exclusion criteria. Overall, 65 surgical ICU survivors developed PICS within six months, with an incidence rate of 78.3%. The prevalences were 55.4% and 27.7% at the end of 3 and 6 months after ICU discharge, respectively. Univariate analysis showed that there was a correlation between the occurrence of PICS and the total bilirubin and creatinine levels at ICU admission, APACHE II score, ICU length of stay, and the presence of dialysis (P < 0.05). ICU length of stay was identified as an independent risk factor for the occurrence of PICS in surgical ICU survivors after adjusting for confounders.

CONCLUSION

The overall PICS incidence in surgical ICU survivors was 78.3%, with prevalence gradually decreasing over time to 27.7% within 6 months. For surgical survivors requiring ICU care, the longer the ICU stay, the more likely to develop PICS.

IMPLICATIONS FOR CLINICAL PRACTICE

The findings offer valuable insights into the incidence and risk factors of PICS in surgical ICU survivors, which can help healthcare professionals identify surgical cases at high risk of developing PICS and tailor the treatment effectively.

Functional dependence following intensive care unit-treated sepsis: three-year follow-up results from the prospective Mid-German Sepsis Cohort (MSC)

Background

Surviving sepsis can lead to chronic physical, psychological and cognitive impairments, which affect millions of patients worldwide, including survivors after COVID-19 viral sepsis. We aimed to characterize the magnitude and trajectory of functional dependence and new impairments post-sepsis.

Methods

We conducted a prospective cohort study including sepsis survivors who had been discharged from five German intensive care units (ICUs), until 36 months post-discharge. Primary outcome was functional dependence, defined as ≥1 impaired activity of daily living (ADL; 10-item ADL score <100), self-reported nursing care dependence or nursing care level. Secondary outcome was post-sepsis morbidity in the physical, psychological or cognitive domain. We used a multistate, competing risk model to address competing events in the course of dependence, and conducted multiple linear regression analyses to identify predictors associated with the ADL score.

Findings

Of 3210 sepsis patients screened, 1968 survived the ICU treatment (61.3%). A total of 753 were included in the follow-up assessments of the Mid-German Sepsis cohort. Patients had a median age of 65 (Q1-Q3 56-74) years, 64.8% (488/753) were male and 76.1% (573/753) had a septic shock. Considering competing risk modelling, the probability of still being functional dependent was about 25%, while about 30% regained functional independence and 45% died within the three years post-sepsis. Patients reported a high burden of new and often overlapping impairments until three years post-sepsis. In the subgroup of three-year survivors (n = 330), new physical impairments affected 91.2% (n = 301) while new cognitive and psychological impairments were reported by 57.9% (n = 191) and 40.9% (n = 135), respectively. Patients with pre-existing functional limitations and higher age were at risk for low ADL scores three years after sepsis.

Interpretation

Sepsis survivorship was associated with a broad range of new impairments and led to functional dependence in around one quarter of patients. Targeted measures are needed to mitigate the burden of this Post-Sepsis-Syndrome and increase the proportion of patients that achieve functional improvements.

Funding

This work was supported by the Integrated Research and Treatment Center, Center for Sepsis Control and Care (CSCC) at the Jena University Hospital funded by the German Ministry of Education and Research and by the Rudolf Presl GmbH & Co, Kreischa, Germany.

"The Psychiatric Domain of Post-Intensive Care Syndrome: A Review for the Intensivist"

Post-intensive care syndrome (PICS) is a clinical syndrome characterized by new or worsening changes in mental health, cognition, or physical function that persist following critical illness. The psychiatric domain of PICS encompasses new or worsened psychiatric burdens following critical illness, including post-traumatic stress disorder (PTSD), depression, and anxiety. Many of the established predisposing and precipitating factors for the psychiatric domain of PICS are commonly found in the setting of critical illness, including mechanical ventilation (MV), exposure to sedating medications, and physical restraint. Importantly, previous psychiatric history is a strong risk factor for the development of the psychiatric domain of PICS and should be considered when screening patients to diagnose psychiatric impairment and interventions. Delirium has been associated with psychiatric symptoms following ICU admission, therefore prevention warrants careful consideration. Dexmedetomidine has been shown to have the lowest risk for development of delirium when compared to other sedatives and has been the only sedative studied in relation to the psychiatric domain of PICS. Nocturnal dexmedetomidine and intensive care unit (ICU) diaries have been associated with decreased psychiatric burden after ICU discharge. Studies evaluating the impact of other intra-ICU practices on the development of the psychiatric domain of PICS, including the ABCDEF bundle, depth of sedation, and daily spontaneous awakening trials, have been limited and inconclusive. The psychiatric domain of PICS is difficult to treat and may be less responsive to multidisciplinary post-discharge programs and targeted interventions than the cognitive and physical domains of PICS. Given the high morbidity associated with the psychiatric domain of PICS, intensivists should familiarize themselves with the risk factors and intra-ICU interventions that can mitigate this important and under-recognized condition.

Post-Intensive Care Syndrome in Neurocritical Care Patients

Post-intensive care syndrome (PICS) refers to unintended consequences of critical care that manifest as new or worsening impairments in physical functioning, cognitive ability, or mental health. As intensive care unit (ICU) survival continues to improve, PICS is becoming increasingly recognized as a public health problem. Studies that focus on PICS have typically excluded patients with acute brain injuries and chronic neurodegenerative problems. However, patients who require neurocritical care undoubtedly suffer from impairments that overlap substantially with those encompassed by PICS. A major challenge is to distinguish between impairments related to brain injury and those that occur as a consequence of critical care. The general principles for the prevention and management of PICS and multidomain impairments in patients with moderate and severe neurological injuries are similar including the ICU liberation bundle, multidisciplinary team-based care throughout the continuum of care, and increasing awareness regarding the challenges of critical care survivorship among patients, families, and multidisciplinary team members. An extension of this concept, PICS-Family (PICS-F) refers to the mental health consequences of the intensive care experience for families and loved ones of ICU survivors. A dyadic approach to ICU survivorship with an emphasis on recognizing families and caregivers that may be at risk of developing PICS-F after neurocritical care illness can help improve outcomes for ICU survivors. In this review, we will summarize our current understanding of PICS and PICS-F, emerging literature on PICS in severe acute brain injury, strategies for preventing and treating PICS, and share our recommendations for future directions.

Long-term psychiatric disorders in families of severe COVID-19 patients

Aim

The present study aimed to describe in detail the changes to and assess the risk factors for poor long-term outcomes of psychiatric disorders in families of COVID-19 patients.

Methods

A single-center, retrospective study using questionnaires. Family members of patients admitted to the intensive care unit (ICU) with severe COVID-19 participated. Psychiatric disorders refer to the psychological distress such as anxiety, depression, and posttraumatic stress disorder (PTSD) experienced by the patient's family.

Results

Forty-six family members completed the survey and were analyzed. Anxiety, depression, and PTSD occurred in 24%, 33%, and 2% of family members, respectively, and psychiatric disorders occurred in 39%. On multivariable analysis, living in the same house with the patient was independently associated with a lower risk of psychiatric disorders in families of COVID-19 patients (OR, 0.180; 95% CI, 0.036-0.908; p = 0.038). Furthermore, four family members overcame psychiatric disorders, and six family members newly developed psychiatric disorders during the one-year follow-up period.

Conclusion

Approximately 40% of family members had long-term psychiatric disorders, and some of them overcame the psychiatric disorders, and some newly developed psychiatric disorders over the one-year follow-up. Living in the same house with the patient was possibly significantly associated with the reduction of long-term symptoms of psychiatric disorders, but this result must be interpreted with care. Further large studies are needed to examine the factors associated with the long-term mental status of family members.