Anesthesia for Post Intensive Care

Educational Objectives

The goal of this program is to assess the effectiveness of follow-up services for intensive care unit (ICU) survivors. After hearing and assimilating this program, the clinician will be better able to:

1. Describe post intensive care syndrome (PICS).
2. Review interventions aimed at preventing PICS.
3. Consider future interventions that may address the various needs of ICU survivors.

Summary

Post-intensive care syndrome (PICS): includes a constellation of symptoms manifesting in patients who have survived critical illness; involves physical, cognitive, and psychologic impairments; physical impairment — includes weakness, reduced strength in limb muscles or handgrip, development of arterial thrombosis, dyspnea, dysphagia, chronic pain or risk for chronic pain syndrome, and impaired mobility; cognitive impairment — includes problems related to attention, memory, language, executive functioning, processing and motor speed, and visuospatial abilities; such patients have significant long-term risk for morbidity, especially when returning to work; psychologic impairment — anxiety, depression, posttraumatic stress disorder, and sleep disturbances

Effects of acute illness: inflammation, muscle weakness, and hypoperfusion are frequently treated in the intensive care unit (ICU); patients admitted to ICU also have reduced or no mobility, sleep deprivation, and social isolation, and are on multiple medications (eg, sedatives, pain medications); with all these physical and physiologic issues, patients start developing delirium, become malnourished, have anxiety, and are prone to developing pain; clinicians should maintain awareness of patients after ICU discharge as they may develop cognitive or psychologic problems or new or worsening organ system failures, or have ongoing weakness

ICU Liberation Bundle: the Society of Critical Care Medicine (SCCM) developed a bundle of best practices (ABCDEF bundle) to prevent PICS; when first published in 2018, the bundle included only ABCD; E and F were added later; the acronym stands for assess, prevent, and manage pain, spontaneous awakening and spontaneous breathing trials, choice of analgesia and sedation, delirium assessment, prevention, and management (nonpharmacologic intervention remains the gold standard), early mobility and exercise (resource-intensive to implement), and family engagement and empowerment; implementing the bundle reduces delirium and coma days by 25% to 50%; delirium is an independent predictor for mortality; discharges to nursing and rehabilitation facilities are reduced by 40%; ICU readmissions are reduced by 50%; physical restraint use is reduced by >60%, which is significant as physically restraining patients may contribute to delirium; the likelihood of hospital death within 7 days is decreased by 68%

Medical needs after ICU discharge: after discharge from the ICU, patients still have several complex medical needs and require optimal coordination of care; pharmacy services — several medicines are initiated and discontinued during their stay in the ICU or during hospitalization; durable medical equipment — patients might have lost limbs or have reduced mobility and are provided with wheelchairs or other mobility devices; several survivors of acute respiratory distress syndrome (ARDS) may require oxygen; subspecialty medical care — especially important when considering high rates of acute kidney injury that might require dialysis; such patients are referred to nephrologists for further treatment; optimal rehabilitation therapy — includes continuing mobilization and exercise, occupational therapy services, nutritional services, speech language pathology, and screening for returning to work; improving health habits — patients with substance abuse or who are smokers are provided with smoking cessation education and services or substance abuse treatments; diagnosis and management of cognitive impairment — a highly specialized service as it may require neural assessment and involve neuropsychology; includes speech language, language therapy, rehabilitation, and screening for return to work; diagnosis and management of mental health problems — after critical illness, patients are highly prone to high anxiety states, depression, and adjustment problems during recovery

Aftercare and recovery clinics: also known as post-ICU care clinics; typically, patients tend to follow up with the primary care physician after acute hospitalization (may or may not involve ICU admission); a good place for anesthesiologist intensivists; understand the concepts of post-ICU care and PICS

Evidence: Jones et al (2003) — demonstrated benefit with use of a rehabilitation manual to guide patient recovery; PraCTICaL study (Cuthbertson et al [2009]) — randomized patients to control vs nurse-led clinic for follow-up; showed no increase in health-related quality of life in patients visiting the nurse-led clinic; RECOVER trial (Walsh et al [2015]) — reported increased patient satisfaction after staying in some type of post-ICU clinic but showed no difference in physical recovery and quality of life; Cochrane review (Schofield-Robinson et al [2018]) — reported no evidence showing that post-ICU care clinics were effective in addressing impairments across various domains of recovery in adults who were admitted to an ICU for long-term; the secondary objective evaluated the timing of the services provided, whether the services were provided by nurses or physicians, and services provided in various countries, but none had any effect

SCCM THRIVE project: despite data suggesting no effect of care in aftercare and recovery clinics in patients discharged from ICU, several clinics have been set up around the world, the reason being the absence of sufficient evidence to determine whether these aftercare services are valuable or not; various societies, including SCCM, and other health care systems have supported the creation of post-ICU care clinics; SCCM recently developed the THRIVE task force, which is an initiative that has created a consortium of learning collaboratives that will study the feasibility and effectiveness of ICU aftercare interventions; SCCM is funding probably the largest qualitative study involving ICU survivors, caregivers, and physicians

Looking ahead: services that are effective and meaningful should be practiced in patients following ICU discharge; consider response rate of various conditions; not all patients who are critically ill are equal (ie, a continuum of less critically ill to severely critically ill); consider the concepts of patient phenotypes and individualization; inflammation does not affect all patients equally; certain phenotypes of ARDS are more severe and contribute to severity of critical illness, ie, it may not necessarily be the same in patients with mild ARDS; determination of management factors defining PICS include bundles that provide guidelines that assist in prevention of PICS; data points in electronic medical records from these very critically ill patients could potentially be analyzed through artificial intelligence to obtain predictive models, eg, which patient will respond to post-ICU care services based on phenotypes displayed during illness; the best time for starting specialized care and integration services is not greatly understood; patients may have symptoms for years after hospitalization (optimal timing of initiating rehabilitation therapy remains unclear) and may also have enhanced recovery after surgery-type protocolization; several interventions can be implemented to get patients back to baseline as early as possible; developing or incorporating enhanced recovery after ICU is also possible

Readings

Cuthbertson BH, Rattray J, Campbell MK, et al. The PRaCTICaL study of nurse led, intensive care follow-up programmes for improving long term outcomes from critical illness: a pragmatic randomised controlled trial [published correction appears in BMJ. 2009;339. doi: 10.1136/bmj.b4445]. BMJ. 2009;339:b3723. Published 2009 Oct 16. doi:10.1136/bmj.b3723; Held N, Moss M. Optimizing post-intensive care unit rehabilitation. Turk Thorac J. 2019;20(2):147-152. Published 2019 Apr 1. doi:10.5152/TurkThoracJ.2018.18172; Jones C, Skirrow P, Griffiths RD, et al. Rehabilitation after critical illness: a randomized, controlled trial. Crit Care Med. 2003;31(10):2456-2461. doi:10.1097/01.CCM.0000089938.56725.33; Marra A, Ely EW, Pandharipande PP, et al. The ABCDEF bundle in critical care. Crit Care Clin. 2017;33(2):225-243. doi:10.1016/j.ccc.2016.12.005; Murphy DJ, Weaver BW, Elizabeth Sexton M. Meeting the needs of ICU survivors: A gap requiring systems thinking and shared vision. Crit Care Med. 2023;51(2):319-335. doi:10.1097/CCM.0000000000005754; Schofield-Robinson OJ, Lewis SR, Smith AF, et al. Follow-up services for improving long-term outcomes in intensive care unit (ICU) survivors. Cochrane Database Syst Rev. 2018;11(11):CD012701. Published 2018 Nov 2. doi:10.1002/14651858.CD012701.pub2; Walsh TS, Salisbury LG, Merriweather JL, et al. Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: The RECOVER randomized clinical trial. JAMA Intern Med. 2015;175(6):901-910. doi:10.1001/jamainternmed.2015.0822.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Gray was recorded at 2023 Annual Convention and Conclave of the American Osteopathic College of Anesthesiologists, held September 30 to October 3, 2023, in Saint Petersburg, FL, and presented by the American Osteopathic College of Anesthesiologists. For information on future CME activities from this presenter, please visit www.aocaonline.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

AN660201

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.