Prevalence and Long-Term Prognosis of Post-Intensive Care Syndrome after Sepsis: A Single-Center Prospective Observational Study

Comprehensive assessment and progression of health status during neurorehabilitation in survivors of critical illness: a prospective cohort study

BACKGROUND

Critical illness survivors frequently suffer from long-term impairments, often described as post-intensive care syndrome (PICS). PICS encompasses physical, cognitive, and mental impairments. Additionally, the term intensive care unit (ICU)-acquired weakness (ICUAW) was coined for muscle weakness after critical illness. Research on the progression and outcome of individuals affected by PICS and ICUAW is scant. Thus we aimed to assess the health status and its progression during neurorehabilitation in critically ill patients using comprehensive outcome measures, describe the prevalence of PICS, and evaluate factors associated with rehabilitation outcomes.

METHODS

Patients with mixed reasons for critical illness who received ≥ 5 days of mechanical ventilation on the ICU and who were admitted to neurorehabilitation, were eligible to be included in this prospective cohort study. A number of outcomes (patient-reported, clinician-reported, and performance) were assessed after discharge from the ICU (V1) and shortly before discharge from inpatient neurorehabilitation (V2). The prevalence of PICS, defined as having at least one impairment in any PICS dimension), was calculated at V1 and V2. Multiple logistic regressions were conducted to identify factors associated with rehabilitation outcome (poor outcome = modified Rankin Scale > 2) and ICUAW at V2 (MRC sum score < 48).

RESULTS

In total, 250 critical illness survivors (62 ± 14 years, 34% female, median stay on ICU 55 days, median inpatient rehabilitation 65 days) were included. 11 participants (4.4%) died before V2. All outcomes improved significantly during rehabilitation except sensory impairment and pain. PICS was present in 96% at V1 and in 85% at V2, whereby mainly the physical domain (V1: 87%, V2: 66%; ICUAW with MRC sum score < 48) and the cognitive domain (V1:65%, V2:55%; Montreal Cognitive Assessment < 26) were affected. Mental impairment was lower (V1:48%, V2:29%; Hospital Anxiety and Depression Scale > 7), but still affected a considerable number of participants. Accordingly, health-related quality of life was rather low at discharge (0.64 ± 0.28, index value of EQ-5D-5L). MRC sum score at V1, duration of mechanical ventilation, and female gender were significantly associated with a poor rehabilitation outcome. Grip strength in % of reference at V1, age, female gender, and comorbidities were significantly associated with persistent ICUAW at discharge.

CONCLUSIONS

Despite significant improvements during rehabilitation, survivors after critical illness experience a substantial burden of PICS and ICUAW at discharge from rehabilitation care. Survivors of critical illness require long-term follow-up, supportive structures, and tailored long-term multi-disciplinary therapies even after intensive rehabilitation.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00021753. Registered 03 September, 2020. https://drks.de/search/en/trial/DRKS00021753 .

Long-term sequelae and management following obstetric sepsis

The long-term consequences of obstetric sepsis have been a growing area of concern requiring attention. This narrative review summarizes the existing literature on the long-term sequelae of sepsis, with a focus on the antepartum and postpartum periods. In this article, we discuss risk factors for and epidemiology of post-sepsis syndrome (PSS) and related long-term medical conditions. We include recommendations for screening for PSS and management strategies involving multidisciplinary teams. PSS and other long-term medical and psychological sequelae of sepsis impact individuals and their communities greatly, including the obstetric population. There is a need for improved identification, management, and coordination of care for long-term complications of sepsis. Gaps in the literature for future study include identifying specific needs of the obstetric population in the weeks, months, and years following a sepsis event.

Post-sepsis psychiatric disorder: Pathophysiology, prevention, and treatment

Post-sepsis psychiatric disorder, encompassing anxiety, depression, post-traumatic stress disorder and delirium, is a highly prevalent complication secondary to sepsis, resulting in a marked increase in long-term mortality among affected patients. Regrettably, psychiatric impairment associated with sepsis is frequently disregarded by clinicians. This review aims to summarize recent advancements in the understanding of the pathophysiology, prevention, and treatment of post-sepsis mental disorder, including coronavirus disease 2019-related psychiatric impairment. The pathophysiology of post-sepsis psychiatric disorder is complex and is known to involve blood-brain barrier disruption, overactivation of the hypothalamic-pituitary-adrenal axis, neuroinflammation, oxidative stress, neurotransmitter dysfunction, programmed cell death, and impaired neuroplasticity. No unified diagnostic criteria for this disorder are currently available; however, screening scales are often applied in its assessment. Modifiable risk factors for psychiatric impairment post-sepsis include the number of experienced traumatic memories, the length of ICU stay, level of albumin, the use of vasopressors or inotropes, daily activity function after sepsis, and the cumulative dose of dobutamine. To contribute to the prevention of post-sepsis psychiatric disorder, it may be beneficial to implement targeted interventions for these modifiable risk factors. Specific therapies for this condition remain scarce. Nevertheless, non-pharmacological approaches, such as comprehensive nursing care, may provide a promising avenue for treating psychiatric disorder following sepsis. In addition, although several therapeutic drugs have shown preliminary efficacy in animal models, further confirmation of their potential is required through follow-up clinical studies.

The chain of survival and rehabilitation for sepsis: concepts and proposals for healthcare trajectory optimization

This article describes the structures and processes involved in healthcare delivery for sepsis, from the prehospital setting until rehabilitation. Quality improvement initiatives in sepsis may reduce both morbidity and mortality. Positive outcomes are more likely when the following steps are optimized: early recognition, severity assessment, prehospital emergency medical system activation when available, early therapy (antimicrobials and hemodynamic optimization), early orientation to an adequate facility (emergency room, operating theater or intensive care unit), in-hospital organ failure resuscitation associated with source control, and finally a comprehensive rehabilitation program. Such a trajectory of care dedicated to sepsis amounts to a chain of survival and rehabilitation for sepsis. Implementation of this chain of survival and rehabilitation for sepsis requires full interconnection between each link. To date, despite regular international recommendations updates, the adherence to sepsis guidelines remains low leading to a considerable burden of the disease. Developing and optimizing such an integrated network could significantly reduce sepsis related mortality and morbidity.

Post-intensive care syndrome: Recent advances and future directions

Post-intensive care syndrome comprises physical, cognitive, and mental impairments in patients treated in an intensive care unit (ICU). It occurs either during the ICU stay or following ICU discharge and is related to the patients' long-term prognosis. The same concept also applies to pediatric patients, and it can greatly affect the mental status of family members. In the 10 years since post-intensive care syndrome was first proposed, research has greatly expanded. Here, we summarize the recent evidence on post-intensive care syndrome regarding its pathophysiology, epidemiology, assessment, risk factors, prevention, and treatments. We highlight new topics, future directions, and strategies to overcome post-intensive care syndrome among people treated in an ICU. Clinical and basic research are still needed to elucidate the mechanistic insights and to discover therapeutic targets and new interventions for post-intensive care syndrome.

Cognitive Impairment, Physical Impairment, and Psychological Symptoms in Intensive Care Unit Survivors

BACKGROUND

Post-intensive care syndrome (PICS) affects 25% to 50% of adults who survive an intensive care unit (ICU) stay. Although the compounding of PICS impairments (cognitive, physical, and psychological) could intensify the syndrome, research on relationships among impairments is limited, particularly in patients with delirium.

OBJECTIVES

To examine associations among PICS impairments and examine delirium status and its relationship to PICS impairments at ICU discharge and 1 month later.

METHODS

A descriptive, correlational study of adults who survived an ICU stay. Participants completed measures for depression, anxiety, posttraumatic stress, physical function, functional status, and cognition at ICU discharge and 1 month later. Relationships among PICS impairments were examined with Spearman correlations; differences in impairments by delirium status were assessed with t tests.

RESULTS

Of 50 enrolled participants, 46 were screened for PICS impairment at ICU discharge and 35 were screened 1 month later. Cognitive impairment was the most common impairment at both time points. A positive correlation was found between cognition and functional status at ICU discharge (ρ = 0.50, P = .001) and 1 month later (ρ = 0.54, P = .001). Cognition and physical functioning were positively correlated 1 month after discharge (ρ = 0.46, P = .006). The group with delirium had significantly lower functional status scores than the group without delirium at ICU discharge (P = .04).

CONCLUSIONS

The findings suggest a moderate correlation between cognitive and physical impairments. This relationship should be explored further; ICU survivors with undiagnosed cognitive impairment may have delayed physical recovery and greater risk for injury.

Understanding Post-Sepsis Syndrome: How Can Clinicians Help?

Sepsis is a global health challenge, with over 49 million cases annually. Recent medical advancements have increased in-hospital survival rates to approximately 80%, but the escalating incidence of sepsis, owing to an ageing population, rise in chronic diseases, and antibiotic resistance, have also increased the number of sepsis survivors. Subsequently, there is a growing prevalence of "post-sepsis syndrome" (PSS). This syndrome includes long-term physical, medical, cognitive, and psychological issues after recovering from sepsis. PSS puts survivors at risk for hospital readmission and is associated with a reduction in health- and life span, both at short and long term, after hospital discharge. Comprehensive understanding of PSS symptoms and causative factors is vital for developing optimal care for sepsis survivors, a task of prime importance for clinicians. This review aims to elucidate our current knowledge of PSS and its relevance in enhancing post-sepsis care provided by clinicians.

Cancer and sepsis

Sepsis is one of the leading causes of death worldwide. While mortality is high regardless of inciting infection or comorbidities, mortality in patients with cancer and sepsis is significantly higher than mortality in patients with sepsis without cancer. Cancer patients are also significantly more likely to develop sepsis than the general population. The mechanisms underlying increased mortality in cancer and sepsis patients are multifactorial. Cancer treatment alters the host immune response and can increase susceptibility to infection. Preclinical data also suggests that cancer, in and of itself, increases mortality from sepsis with dysregulation of the adaptive immune system playing a key role. Further, preclinical data demonstrate that sepsis can alter subsequent tumor growth while tumoral immunity impacts survival from sepsis. Checkpoint inhibition is a well-accepted treatment for many types of cancer, and there is increasing evidence suggesting this may be a useful strategy in sepsis as well. However, preclinical studies of checkpoint inhibition in cancer and sepsis demonstrate results that could not have been predicted by examining either variable in isolation. As sepsis management transitions from a 'one size fits all' model to a more individualized approach, understanding the mechanistic impact of cancer on outcomes from sepsis represents an important strategy towards delivering on the promise of precision medicine in the intensive care unit.

Post-Intensive Care Syndrome: A Problem Cannot Be Ignored in ICU. Comment on Inoue et al. Prevalence and Long-Term Prognosis of Post-Intensive Care Syndrome after Sepsis: A Single-Center Prospective Observational Study. J. Clin. Med. 2022, 11, 5257

Recently, we read with great interest the article by Inoue et al. [...].