Unmasking the hidden aftermath: postintensive care unit sequelae, discharge preparedness, and long-term follow-up

Teixeira, Cassiano; Rosa, Regis Goulart

doi:10.62675/2965-2774.20240265-en

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REVIEW • Crit. Care Sci. 36 • 2024 • https://doi.org/10.62675/2965-2774.20240265-en copy

Unmasking the hidden aftermath: postintensive care unit sequelae, discharge preparedness, and long-term follow-up

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ABSTRACT

A significant portion of individuals who have experienced critical illness encounter new or exacerbated impairments in their physical, cognitive, or mental health, commonly referred to as postintensive care syndrome. Moreover, those who survive critical illness often face an increased risk of adverse consequences, including infections, major cardiovascular events, readmissions, and elevated mortality rates, during the months following hospitalization. These findings emphasize the critical necessity for effective prevention and management of long-term health deterioration in the critical care environment. Although conclusive evidence from well-designed randomized clinical trials is somewhat limited, potential interventions include strategies such as limiting sedation, early mobilization, maintaining family presence during the intensive care unit stay, implementing multicomponent transition programs (from intensive care unit to ward and from hospital to home), and offering specialized posthospital discharge follow-up. This review seeks to provide a concise summary of recent medical literature concerning long-term outcomes following critical illness and highlight potential approaches for preventing and addressing health decline in critical care survivors.

Critical illness; Patient discharge; Hospital-to-home transition; Mental health; Cognition; Cardiovascular diseases; Intensive care units

Disorder	Consequences
Immunosuppression	Infections represent one of the most important reasons for readmission among critical patients, and a substantial portion of these could be averted. Furthermore, preventing readmission appears to reduce long-term patient mortality
ICU-acquired weakness	Prolonged mechanical ventilation, compromised ambulation, impaired ADL, pharyngeal muscle weakness, swallowing difficulties, increased risk of aspiration, employment difficulties, and/or reduced health-related quality of life for ≥ 5 years
Nutritional compromise	Compromised physical and neurocognitive recovery
Entrapment neuropathy	Foot or wrist drop, hindering rehabilitation and functioning
Frailty	Functional disability, new nursing home admission, increased post-ICU mortality
Cognitive dysfunction	Decreased attention, concentration, processing speed, memory, and/or executive dysfunction for ≥ 5 years; impact on employment and health status
Psychological disorders	Experiencing depressive symptoms, anxiety, PTSD, suicidality, and/or substance misuse for ≥ 8 years
Pressure injuries	Prolonged presence may impede return to work; associated with increased post-ICU mortality
Risk of falls	Falls can be potentially devastating for debilitated patients, and their prevention (e.g., muscle strengthening and educational measures) can significantly reduce morbidity
Oral complications	Gingivitis, dental caries, tooth injury or loss, requiring longer-term dental follow-up
Endocrinopathies	Disruption of thyroid, adrenal function, and hypothalamic–pituitary axis, affecting endocrine homeostasis and sexual function
Musculoskeletal disorders	Frozen joints, contractures, and heterotopic ossification
Changes in appearance	Alopecia, scarring, and disfigurement, affecting social reintegration
Taste changes	Difficulties with feeding and nutrition
Hearing or vision changes	Delayed recovery and return to home and work
Procedure-related trauma	Rectal and urethral injury, vocal cord dysfunction with altered phonation, tracheal stenosis, hindering ADL, rehabilitation, and return to home and work
Renal dysfunction	Chronic impairment of the glomerular filtration rate, necessitating renal-replacement therapy, compromising health-related quality of life, and leading to increased health care use
Cardiovascular disorders	Sepsis and COVID-19 survivors exhibit higher rates of cardiovascular and thromboembolic events

Bundle element	Rationale
A. Assess, prevent, and manage pain	With adequate pain control, many patients can tolerate mechanical ventilation without sedative infusions
B. Both SATs and SBTs	SATs and SBTs are associated with a faster liberation from mechanical ventilation and reduced mortality
C. Choice of sedation	Nonbenzodiazepine sedation is associated with lower rates of delirium compared to benzodiazepines
D. Delirium	Delirium is common and associated with increased mortality. Regular screening improves recognition
E. Early mobility and exercise	Early mobility is linked to a shorter duration of delirium
F. Family engagement and empowerment	Family involvement improves satisfaction and communication and reduces delirium rates

Early critical ill care, mainly in sepsis	Early identification, broad-spectrum antibiotics, initial fluid bolus for patients with low systolic blood pressure or elevated lactate, and source control
Avoiding iatrogenic complications	The ABCDEF bundle
Deresuscitation and volume management	Positive fluid balance is associated with inability to ambulate, higher risk of development of multiple organ dysfunction, and discharge to a postacute care facility
Reconciling and titrating chronic medications	Medication lists are often adjusted at ICU discharge, and errors are common. Beyond reconciling a patient’s list of medications, clinicians must also consider the need for dosing adjustments
Avoiding aspiration	Aspiration following critical illness because of muscle weakness, cognitive impairment, and ongoing delirium. Bedside swallow evaluations may be helpful to assess swallow function. If the meal tray arrives hours later when patients are sleepy or confused, they may still be at high risk for aspiration
Avoiding reinfection	Strategies to reduce risk for secondary, hospital-acquired infection and infection-related readmission include stopping or narrowing antibiotics as soon as possible during the initial hospitalization, ensuring patients are up to date on recommended vaccines, counseling patients about their high risk for recurrent sepsis and the importance of seeking medical attention for signs or symptoms of infection, and having a lower threshold to evaluate and treat infectious signs and symptoms in recently septic patients
Tailoring nutrition	Critically ill patients often experience decreased appetite, an increased risk of aspiration, and delirium, which hinder adequate oral energy intake. Maintaining a hypercaloric and hyperprotein enteral nutrition supply, particularly after the first week of acute critical illness, can bring benefits in accelerating muscle recovery
Optimizing sleep	Sleep disruption is ubiquitous in patients admitted to the ICU. The implementation of chronobiological strategies (rhythmically occurring cues, such as reducing light, noise, feeding, temperature, activity, medical and nursing interventions, and sedatives), as well optimizing mechanical ventilation strategies, may facilitate sleep and recovery of postcritical illness

Functional domain	Before critical illness	During critical illness	After critical illness
Mental health	Preexisting mental health problems (anxiety, depression, or posttraumatic stress disorder)	Memories of frightening experiences in ICU	Early symptoms of anxiety, depression, or posttraumatic stress disorder
Physical	Preexisting functional disability Frailty Preexisting cognitive impairment
Cognition	Preexisting cognitive dysfunction	Incidence and duration of delirium Sedation (benzodiazepines) Sepsis Shock Hypoxia Acute respiratory distress syndrome Life support (invasive mechanical ventilation)

Domain	Screening test	Comments	Recommendation
Anxiety Depression	HADS HADS	A score of 8 or greater on the anxiety or depression subscale is used to identify symptoms of clinically significant anxiety or depression	Strong Strong
Posttraumatic stress disorder	IES-R or the abbreviated IES-6	The optimal screening threshold has been established as 1.6 (IES-R) or 1.75 (IES-6)	Weak
Physical function	6-min walk and/or EuroQol-5D-5L	Can be evaluated as a percent predicted against available normative data Includes assessments of mobility, self-care, and usual activities in addition to pain and anxiety/depression	Weak Weak
Cognition	Montreal Cognitive Assessment (MoCA)	Mild cognitive impairment defined as a score of 18–25, moderate as 10–17, and severe as less than 10	Strong

Strategy	Potential favorable outcomes
ICU follow-up clinics	Reduction in early unplanned patient’s readmissions⁽¹¹²⁾ Reduction in morbidity and mortality among patients who received recommended postsepsis care⁽¹¹³⁾ Improvement in QoL of patients⁽¹¹⁴⁾ Improvement in patient satisfaction⁽¹¹⁶⁾ Reduction of ICU-staff burnout⁽¹¹⁵⁾
Peer support	Reduction of psychological morbidity⁽¹¹⁷⁾
Home-based care	Reduction in unplanned patient readmissions⁽¹¹⁹⁾
Improving transition to primary care	?⁽¹¹⁸⁾
Telehealth	Telerehabilitation interventions for stroke survivors have equal effects compared with face-to-face therapy⁽¹²⁰⁾

Associação de Medicina Intensiva Brasileira - AMIB Rua Arminda, 93 - 7º andar - Vila Olímpia, CEP: 04545-100, Tel.: +55 (11) 5089-2642 - São Paulo - SP - Brazil
E-mail: ccs@amib.org.br

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[1] Corresponding author: Cassiano Teixeira. Departamento de Medicina Interna. Universidade Federal de Ciências da Saúde de Porto Alegre. Rua Sarmento Leite, 245. Zip code: 90050-170 - Porto Alegre (RS), Brazil. E-mail: cassiano.rush@gmail.com