Domain
Diagnosis
Prevention
Rehabilitation
Cognition
Use a validated, screening test at time of discharge or initial follow-up (e.g., Montreal Cognitive Assessment)
ABCDEF bundle to minimize delirium and preserve physical function
1. Compensation and rehabilitation therapy through consultation with expert providers
2. Cognitive exercises
3. Prioritize early occupational and physical therapy
Mental health
1. ABCDEF bundle
2. ICU diary
3. Avoid hypoglycemia and sustained, severe hypoxemia as potential strategies to prevent long-term psychological distress
1. Consultation with psychologists and/or psychiatrists based on symptoms
2. Consideration of pharmacologic treatment
Physical function
Physical examination, including use of standardized scoring systems, and ancillary testing if necessary
ABCDEF bundle, with a focus on early occupational and physical therapy
1. Continued occupational and physical therapy
Principles of Management
Diagnosis
Survivors of critical illness are at risk for PICS development, and in particular those who experience shock and respiratory failure requiring mechanical ventilation. Risk factors associated with long-term physical and/or neuropsychological impairment include sepsis, acute respiratory distress syndrome (ARDS), multi-system organ failure, prolonged ICU length of stay, duration of delirium, glucose dysregulation, and the use of corticosteroids [2, 5–9].
Physical and neuropsychological impairment should be screened for at the time of hospital discharge to guide the procurement of post-acute care services (Table 32.2). Physical impairment is common following critical illness, can be measured using a standardized scale, and frequently contributes to the need for skilled care or acute rehabilitation facility placement. Several validated options exist to examine functional status, and specific areas of functional abilities, clinically. Cognitive impairment is an under-recognized consequence of critical illness. In a prospective study of survivors of shock and respiratory failure, Pandharipande et al. revealed that 40 % of survivors performed at a level consistent with moderate traumatic brain injury at 3 months, 26 % performed at a level consistent with mild Alzheimer’s disease, and these impairments frequently persisted [8]. Given its prevalence, providers should screen for cognitive impairment in ICU survivors with suspected PICS. A number of validated screening tools exist to identify cognitive impairment, including the Mini Mental Status Exam, the Mini-Cog, and the Montreal Cognitive Assessment (MoCA). As a simple, highly sensitive, and validated test, the MoCA is arguably the best screening tool to detect mild cognitive impairment in ICU survivors [10]. Psychiatric illness seen in PICS manifests as symptoms of anxiety, depression, or post-traumatic stress disorder (PTSD) [14].
Table 32.2
Clinical strategies to screen for neuropsychological and physical impairment after critical illness
Domain | Test | Range | Score interpretation |
---|---|---|---|
Cognition | Montreal Cognitive Assessment (MoCA) [10] | 0–30 | Normal (>25) Impairment: Mild (18–25) Moderate (10–17) Severe (<10) |
Depression | Hospital Anxiety and Depression Scale [3] | 0–21 | Normal (0–7) Abnormal (≥8) |
Anxiety | Hospital Anxiety and Depression Scale [3] | 0–21 | Normal (0–7) Abnormal (≥8) |
Post-traumatic stress disorder | Post-Traumatic Stress Syndrome 10-Questions Inventory (PTSS-10) [4] | 0–70 | Normal (0–34) Impaired (≥35) |
Physical function | Activities of Daily Living [11] | 0–6 | Independence for activities of bathing, dressing, toileting, transferring, continence, and feeding would sum to 6 |
Physical function, strength | Medical Research Council examination [12] | 0–60 | ICU-acquired paresis defined as sum score less than 48 |
Physical function | Timed Up and Go Test [13] | Time required to stand, walk 3 m, return, and sit | Longer times (>14 s) associated with adverse outcomes, including falls |
Prevention and Rehabilitation
A growing body of literature supports the use of the “ABCDEF” bundle as a potential means to mitigate the risk of PICS [15]. The components of the ABCDE bundle include the coordination of sedation minimization and standardized ventilator weaning [16], delirium monitoring, prevention, and management, and early occupational and physical therapy [17]. When coupled with family engagement and empowerment, the bundle is transformed to the ABCDEF bundle. The benefits of an ABCDE bundle include reduced duration of delirium, reduced incidence of ventilator-associated events, increased ventilator-free days, and improved functional outcomes at discharge with increased likelihood of return to functional independence [16–20].
Components of the ABCDEF Bundle
A Recommended Strategy to Mitigate the Risk of Post-intensive Care Syndrome
Assess, Prevent, and Manage Pain
Daily assessment with validated scales, such as the behavioral pain scale
Prevention and management with goal-directed treatment for pain
Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)
Daily safety screen
Daily sedation interruption and/or minimization of sedation use to target
Use of sedation scales in goal-directed delivery of medications
Daily ventilator weaning attempt
Choice of Analgesia and Sedation
Choice of agent and delivery modality, continuous versus intermittent
Delirium: Assess, Prevent, and Manage
Daily assessment in all ICU patients
Avoidance or minimization of medications that exacerbated delirium
Active management with non-pharmacologic and appropriate pharmacologic treatment
Early Mobility and Exercise
Daily exercise regimens, including ambulation as tolerated
Family Engagement and Empowerment
Engage and communicate with families on rounds as active participants in patient care
Facilitate family participation with care tasks in the ICU (e.g. cleaning, feeding)
To complement the ABCDEF bundle, an effective strategy to reduce psychological distress in survivors is the use of the ICU diary [21]. The ICU diary has been shown to reduce post-ICU PTSD symptoms. Used widely throughout Europe (www.icu-diary.org), yet with limited use in the United States given traditionally uncoordinated care between acute care and post-discharge care, an ICU diary is a notebook within which doctors, nurses, family members, and patient visitors can record, in patient-friendly language, information about the patient’s hospital course and messages from friends and family. The ICU diary may also include pictures of the patient during the course of their illness. Post-discharge, patients review the content of the diary with a health care provider as a strategy to fill gaps in their memory regarding the hospitalization and to realign delusional memories with an accurate depiction of the illness narrative. Beyond the positive effect that the ICU diary can have on the patient’s psychological condition, its use also appears beneficial to family members. Because it is increasingly recognized that family members of survivors also experience lasting psychological effects, known as Post-Intensive Care Syndrome- Family (PICS-F) [1], the ability to mitigate long-term psychological distress in caregivers is an important one.