Written by Rachel Jennings
With the discovery of post-intensive care syndrome (PICS), there has been a paradigm shift in the approach to the critically ill patient, focusing on delirium prevention, sedation stewardship, and early mobility. These decrease mortality and improve physical and cognitive recovery.
Why does this matter?
With the recent surge in the COVID-19 pandemic, we as ED providers have been performing critical care medicine more than ever before. Hospitals are full, and boarding ICU patients in the ED has become the norm. It is imperative that we approach these patients holistically, and not only target the underlying physiology of their “admission diagnosis,” but also the myriad iatrogenic and organic disease processes that are inextricably linked to their critical illness and full clinical course.
Survivin’ and thrivin’
Many of the factors affecting long- term survivorship have been summed up by the catch all phrase, ‘Post-intensive care syndrome’ (PICS). PICS is a well-studied, “form of cognitive impairment, physical impairment, and/or mental health impairment,” in patients that survive their ICU stay.
Here is a quick overview of how we are changing the way we treat these patients to reduce PICS.
Delirium: Don’t underestimate it. Delirium in the ICU is an independent predictor of mortality and morbidity. Tools such as the Confusion Assessment Method for ICU (CAM-ICU) and the Intensive Care Delirium Screen Checklist help with early diagnosis. The timing to diagnose and treat is imperative. Duration of delirium is a primary risk factor for the development of acquired dementia that can persist after discharge.
Sedation & Paralysis: Lay off the heavy stuff. Use guideline driven light sedation strategies and lung protective vent settings. If you have patients boarding overnight, consider a spontaneous awakening trial and spontaneous breathing trial in order to lighten sedation and more quickly liberate patients from the vent.
Immobility: Early mobility is key. Aggressive PT/OT is imperative, as it helps mitigate muscle wasting and ICU acquired weakness. Compliance with the ABCDEF bundle (of which early exercise is a core component) is, “associated with lower likelihood of discharge to a facility, less delirium, and lower in-hospital death.”
ICU Survivorship-The Relationship of Delirium, Sedation, Dementia, and Acquired Weakness. Crit Care Med. 2021 Aug 1;49(8):1227-1240. doi: 10.1097/CCM.0000000000005125.