Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade

critical illness. Post-intensive care syndrome (PICS) describes new or worsening impairments in physical,

cognitive, or mental health status after critical illness and persisting beyond acute care hospitalization.

Physical impairments include both pulmonary dysfunction and neuromuscular weakness. Impairments

in memory and executive functioning are examples of cognitive dysfunction. Mental health impairments

include depression, posttraumatic stress disorder, and anxiety. Medication management including glucose

control, use of the ABCDEF bundle, and review of medication lists at every transition of care are important

roles of the pharmacist to prevent PICS. Family members can also have PICS, termed PICS-F, in which these

individuals have depression, posttraumatic stress disorder, anxiety, and prolonged grief. SCCM has taken

progressive steps to help clinicians and families recognize the prolonged PICS and PICS-F through THRIVE.

The establishment of an ICU follow-up clinic is one proposed method to manage long-term complications

of patients with PICS and family members of PICS-F through optimization of physical, cognitive, and

mental health; improved coordination of care; and reduction in health care use. The pharmacist should be

considered a key member of the PICS clinic team who performs complete medication management on all

patients seen in the clinic.

Physical impairment: A prospective, longitudinal study of 109 survivors with ARDS was conducted.

Median (Interquartile Range) Total Lung Capacity (TVC) was 92% (77-97%), 92% (82–101%), and

95% (81–103%) of predicted value, respectively, at 1, 6, and 12 months after ICU discharge. Forced

expiratory volume in 1 second (FEV1) was 75% (58–92%), 85% (69–98%), and 86% (74–100%) of

predicted value, respectively, at 1, 6, and 12 months after ICU discharge. Six-minute walk test was 49%,

64%, and 66% of predicted value, respectively, at 1, 6, and 12 months after ICU discharge. These 109

survivors of ARDS were further analyzed annually up to 5 years after ICU discharge. TVC was 94%

(84–108%), 93% (78–107%), 92% (79–104%), and 94% (78–105%) of predicted value, respectively, at

2, 3, 4, and 5 years after ICU discharge. FEV1 was 87% (75–99%), 79% (66–97%), 85% (68–98%), and

83% (69–98%) of predicted value, respectively, at 2, 3, 4, and 5 years after ICU discharge. Six-minute

walk test was 68%, 67%, 71%, and 76% of predicted value, respectively, at 2, 3, 4, and 5 years after

ICU discharge.

ICU and surgical ICU patients (called the BRAIN-ICU study) estimated the prevalence of long-term

cognitive impairment after critical illness secondary to respiratory failure, cardiogenic shock, or septic

shock (N Engl J Med 2013;369:1306-16). Delirium was the strongest independent predictor of cognitive

impairment in the 50% of patients after critical illness. A Repeatable Battery for Neuropsychological

Status (RBANS) score similar to Alzheimer disease (2 standard deviations below the population mean)

was found in 26% of patients, and a score similar to moderate traumatic brain injury (1.5 standard

deviations below the population mean) was found in 40% of patients 3 months after discharge. Both

young and older adults, with and without comorbidities, experienced these deficits, which persisted at

12 months in 24% and 34% of these individuals having RBANS scores similar to Alzheimer disease

and moderate traumatic brain injury, respectively.

Mental health impairments: A multicenter, prospective observational cohort study of 821 adult medical

ICU and surgical ICU patients estimate the prevalence of depression, posttraumatic stress disorder

(PTSD), and functional disability after critical illness secondary to respiratory failure, cardiogenic

shock, or septic shock. Depression was found in 149 patients (37%) and 116 patients (33%) at 3 and

6 months after ICU discharge, respectively. Disabilities in basic activities of daily living were found

in 139 patients (32%) and 102 patients (23%) at 3 and 6 months after ICU discharge, respectively.

Disabilities in instrumental activities of daily living were found in 108 patients (26%) and 87 patients

(23%) at 3 and 6 months after ICU discharge, respectively. PTSD was found in 27 patients (7%) at 3 and

6 months after ICU discharge.