Functional outcomes after survival from critical illness (Review)

Functional outcomes after survival from critical illness, and the constellation of disabilities and dysfunction now termed post-ICU syndrome, are getting more attention. The Covid-19 pandemic produced an enormous new cohort of the persistently or permanently disabled as a result of critical illness. This increasing population represent both critical care’s increased success at preventing death, and the unexpected, sometimes devastating consequences.

The list of highly prevalent problems that persist after the ICU is long and saddening:

• Cognitive dysfunction, which persists in 30% of ARDS survivors one year after leaving the ICU—with an incredible 80% experiencing some degree of memory, attention, or concentration issues compared to their premorbid state.

• The cognitive outcomes at one year among ICU survivors occur in younger patients as well as the aged, and are commonly as severe as mild Alzheimer’s-type dementia or moderate traumatic brain injury.

• Physical decline, weakness, and frailty occur in 70% of ARDS survivors persisting after six months of follow-up. Among the elderly, the prevalence is even higher.

• From 25-50% of patients experience depression, anxiety, PTSD, or other significant psychological disturbances.

Pressure injuries, renal failure often requiring dialysis, dysphagia with difficulty eating and drinking, and endocrine disruptions are all also common.

Increasing attention to these issues has led to increasing efforts to develop and test post-ICU rehabilitation programs. So far, the results among highly heterogeneous groups of patients have been unsurprisingly quite mixed, with no best practices or scalable solutions to be found, yet.

Because duration of ICU delirium is one of the strongest predictors of cognitive impairment after ICU discharge, reducing delirium would seem advisable. There’s scarce proof from randomized trials that reducing delirium in and of itself improves outcomes. However, reducing sedation duration and intensity (which also often reduces delirium) is an excellent place to start.

Intensive early mobility held out hopes for reducing post-ICU debilitation, and may have benefit in certain patients. However, a large multicenter trial failed to demonstrate a benefit of intensive daily physical therapy in ventilated patients, and even a small signal of harm—when compared to regular (non-intensive) daily PT, which most ICUs do not even attempt. Earlier use of physical therapy in appropriate ICU patients is a reasonable and potentially beneficial intervention.

A landmark paper in NEJM by Herridge et al provides a vital window into the depth and breadth of problems patients experience after the ICU — information that many physicians don’t know, and because it’s so discouraging, may not want to. Read in NEJM