Ep. 215 - PICS

Hallo zusammen

Die USZ-Fortbildung von vorgestern behandelte unter anderem ein relativ neues, noch nicht so bekanntes IPS-Thema, welches aber viel häufiger vorkommt als man denkt. Hier ist die zusammengefasste Transkription:

Hier wäre auch noch der entsprechnde Artikel:

PICS_Intesive Care Med_2025.pdf

PDF herunterladen • 606KB

Patient Impact and Clinical Context

• 10-20% of ICU patients die, with most survivors discharged alive, though this does not end their medical journey

• Patient testimonies revealed severe post-discharge complications despite positive self-reported health

  • Young student showed cognitive impairment on MoCA test (clock-drawing) at three months, though wanted to return to university

  • Young man at three months could not climb stairs or return to work due to shortness of breath

  • Family reported personality changes, irritability, and increased fatigue in their husband

  • Patients felt lost, powerless, and infantilized during ICU stay, with some experiencing near-death phenomena

  • Compassionate care (nurse introductions, maintaining identity) significantly impacted recovery mindset

  • Communication difficulties and anxiety persisted post-discharge

Definition and Scope of PICS

• PICS encompasses physical, cognitive, and psychological impairments developing during or after ICU stay across three main domains: functional disabilities, cognitive/mental disorders, and additional complications

  • Expanded definition now includes osteopenia with increased fracture risk, metabolic/endocrine dysfunction, chronic pain, sleep disorders, fatigue, and immune depression lasting days to months

• At least one-third of discharged ICU patients experience at least one PICS symptom

• PICS can persist up to five years with consequences including increased dependency, altered quality of life, hospital readmissions, and delayed return to work (at least one-third never return within five years)

Risk Factors

• PICS presentation is heterogeneous with no two patients experiencing identical patterns

• Pre-ICU factors: frailty level strongly correlates with PICS; pre-existing cognitive disorders and anxiety increase risk; age is not predictive despite prior research

• ICU factors: delirium is key risk factor; negative patient experiences directly influence PICS; functional status at discharge matters; ICU length of stay is less predictive than previously thought

• Post-ICU factors: rehabilitation access, follow-up strategies, and social/family support influence outcomes

• PICS remains unpredictable; one study showed physician/nurse quality of life predictions aligned with patient reports in only one-third of cases

Challenges in PICS Identification and Screening

Why Screening is Difficult

• PICS is highly variable, sometimes delayed, and may only appear when patients resume normal activities

• Poorly recognized among healthcare providers and patients, often omitted from discharge summaries, leaving GPs unaware

• No established care pathways, funding mechanisms, or international guidelines exist

Screening Approaches

• Multiple validated tools exist for physical function, autonomy, cognitive screening, psychological health, quality of life, and multidimensional remote assessment

• Who performs screening remains unresolved

  • Specialist physicians rarely screen as it falls outside their scope, particularly in Belgium

  • GPs are ideally positioned due to patient familiarity but face challenges with ICU context understanding and time constraints (screening requires one to two hours per patient with limited access to multidisciplinary resources)

Post-ICU Follow-up Services

Clinic Models

• Post-ICU clinics increasingly developed worldwide to provide integrated, proactive care with continuity

• Models vary widely in selection criteria (selective vs. universal), timing (single-month to one to two years), format (in-hospital vs. remote), screening domains, team composition, and program intensity

• Intensivists potentially have key role given their understanding of ICU events and post-discharge trajectories

• Benefits beyond patient care include quality improvement feedback, staff motivation through patient recovery stories (addressing burnout), and research data generation

Effectiveness Evidence

• Literature shows conflicting results; recent French study suggested potential harm though methodology requires careful interpretation

• Recent systematic review of 14 studies on post-sepsis patients found some clinics improved functional status, mental health, and possibly survival, but evidence remains insufficient to convince hospital and government leaders

• Patients universally report positive satisfaction with post-ICU clinics across all studies, though gap exists between satisfaction and measurable medical outcomes

Managing PICS Throughout Patient Journey

Transition Care

• Transition from ICU to ward represents critical but overlooked intervention opportunity

• Nurse-led programs using educational materials and face-to-face meetings during transition effectively prepare patients by explaining ICU events and expected trajectory, demonstrably reducing anxiety and depression within one week

ICU Prevention

• ABCDF Liberation bundle guides prevention: limiting sedation, early ventilation weaning, optimized sedation/pain management, delirium management, early mobilization, and family involvement

• Evidence shows bundles can reduce delirium incidence and duration but are not fully implemented in routine practice with insufficient evidence on post-discharge PICS effects

• Identified gap: bundles lack nutritional support strategies; Patrick indicates development of additional PICS prevention bundle addressing nutrition

Nutrition as Prevention

• Nutrition is a core prevention strategy for PICS physical domain, focusing on energy, proteins, micronutrients, and metabolic modulation

• Significant knowledge gaps exist on appropriate nutrient doses and inflammation modulation during post-intensive care

• Research ongoing to establish evidence-based guidance

Humanized Care

Patient-Centered Approach

• Humanized care requires deliberate effort to treat patients as individuals with empathy rather than clinical parameters

• Communication must be tailored to each patient's clinical status and cognitive capacity

• Patient experience during ICU stay is closely linked to post-discharge PTSD development

ICU Diaries and Family Engagement

• ICU diaries completed by families or providers effectively prevent PTSD and depression post-ICU, with less robust evidence for anxiety

• Benefits include preventing PICS-family (secondary trauma) and reducing ICU nurse burnout

Environmental Design

• Get-to-know-me boards display patient hobbies, preferences, care team, and daily goals like walking outside room or sitting in chair

• Physical modifications include natural daylight access, therapeutic gardens, family visitation areas, and reduced noise and artificial lighting

Prehabilitation Programs

• Implemented for scheduled ICU admissions (cardiac surgery, thoracic surgery, major cancer surgery, organ transplants) between diagnosis and admission

• Components include nutritional optimization, functional capacity improvement, respiratory enhancement, glucose metabolism optimization, chronic pain management, polypharmacy reduction, mental health development, addiction management, and social support strengthening

  • Overall goals: increase autonomy, improve quality of life, reduce frailty (major PICS risk factor)

• Recent systematic review shows exercise with or without nutrition programs reduces surgical complications, length of stay, and improves quality of life and physical recovery

Peri-Critical Care Pathway

• Critical care should span three periods: pre-critical, critical (ICU), and post-critical

• Resource requirements are similar across all three periods, enabling unified structural approaches with multidisciplinary teams, multi-domain assessment, multidisciplinary programming, and care coordination

Implementation

• Intensivists should lead prehabilitation efforts and shared decision-making on ICU admission, alongside PICS detection, referral, and coordination

• Essential collaboration with surgeons, anesthesiologists, GPs, and specialists aims to restore patient life quality, improve care quality, and educate providers

Post-ICU Follow-Up

• Patrick advocates for structured intensivist-led post-ICU clinics with patient visits at 1, 3, and 12 months

• Requires close GP collaboration, as GPs typically see only 2-3 PICS patients per year, limiting familiarity

  • Without GP engagement and PICS knowledge, care gaps occur between clinic visits

• Intensivists bring specialized knowledge of ICU course and post-ICU sequelae that GPs lack

Education

• Current GP education includes conferences, university meetings, and courses on post-ICU care and PICS

• European Society of Intensive Care Medicine (ESICM) should lead GP education efforts

• Significant educational work needed before developing formal PICS management guidelines

• Challenge: effectively educating all GPs given breadth of required medical knowledge

Key Conclusions

• PICS prevention requires comprehensive multi-domain approach spanning pre-ICU, ICU, and post-ICU periods

• Coordinated pathway design with pre- and post-ICU components is needed

• Education of patients and providers is a key challenge

• Patrick acknowledged University Hospital of Liege post-ICU clinic team as leading implementation example