Post-ICU Syndrome: What intensivists should know
Recognizing the damage done in the business of saving lives
There is a growing recognition of the prevalence of new disabilities in people who have experienced critical illness, particularly those requiring multiple days of mechanical ventilation.
Profound weakness and cognitive impairment are common, as are prolonged psychological symptoms like anxiety and depression.
The wide-ranging symptoms were lumped together and named “post-ICU syndrome” (PICS) by critical care societies around 2010, with a goal more to raise awareness of the widespread phenomenon than to explain it, at first.
Fifteen years later, the truth is we don’t know much more. Like other multisystem disabling syndromes like “long Covid,” PICS isn’t any one thing, and every patient experiences it differently. Systematic research into PICS using traditional reductive methods is unlikely to yield any major breakthroughs, and hasn’t; there will be no biomarker or genetic predisposition to guide a blockbuster targeted therapy.
Instead, there are individually shattered lives, the struggle of former patients and their families to assemble them into some new workable shape, and a small but growing number of institutions and clinicians collaborating to support them.
There are currently about 35 clinics dedicated to helping people living with post-ICU syndrome in the U.S. Virtually all are part of academic medical centers or large integrated healthcare systems (e.g., Brigham, Pittsburgh, UCLA, Mount Sinai, U of M, Geisinger, and Intermountain).
Their approach is resource-intensive, multidisciplinary, and high-touch: at Pittsburgh, intake visits may take three hours, during which a PICS patient may engage with speech therapy, PT, OT, a pharmacist, nutritionist, and multiple physicians and nurses, and be referred into peer support groups and additional services outside the clinic.
Many of these centers have recognized the overlap between the experience and impairments among people experiencing PICS or long Covid, and combined these clinics.
Evidence of benefits has thus far been lacking using traditional metrics. A recent JAMA Insights piece (a mini-review article) is laden with caveats like “difficult to ascertain … data are sparse … may promote … may decrease … may prevent … may enhance …” Clinicians have always agreed that patients with specific impairments like dysphagia, weakness, malnutrition, or anxiety should receive targeted therapies and support. So far, the limited research on PICS hasn’t yet established a benefit from a more holistic approach to the syndrome, nor the clinics that coordinate care.
Yet there is a weak signal both in the research and in the stories of survivors. After making it through harrowing stays in the ICU, being wheeled through a gauntlet of applauding clinicians, only to return home to find their old lives erased—careers impossible, relationships strained, a sense of safety destroyed—there is a longing to be heard, to make meaning of their ordeal and its aftermath.
ICU diaries (written by family members, friends, and clinicians and provided to patients when they recover, to help them understand what happened to them) might improve mental health during prolonged recovery. Ongoing psychotherapy and peer support networks may help reduce isolation and help survivors rebuild their lives.
In a parallel to long Covid, formerly high-functioning ICU survivors who find they are unable to make a complete recovery report feeling relieved and supported by the mere recognition of their syndrome as “real” and not evidence of personal weakness or deficiency.
From the standpoint of practicing intensivists, no specific intervention has been shown to prevent post-ICU syndrome. But because delirium is so strongly associated with both later cognitive impairment and depth of sedation, reducing sedation during mechanical ventilation might enhance many patients’ recovery.
Although the benefits of early mobility are unclear among ICU patients generally, earlier and more intensive physical therapy will likely benefit selected patients who are able and motivated to participate:
The increasing awareness of lasting impairment after critical illness should encourage intensivists to incorporate ad hoc counseling of patients and families into standard practice, when workday conditions permit.
PICU clinics are unlikely to spread far or fast beyond tertiary academic medical centers. We may never know whether they produce a benefit over a basket of referrals to the relevant practitioners in a post-ICU primary care visit.
But their simple existence acknowledges a problem that went unrecognized for years, whose suffering has only recently acquired a name. That simple acknowledgement, and its growing awareness among physicians, honor the struggle of ICU survivors to reclaim and rebuild their lives that were saved at such a high cost.
References
Post–Intensive Care Syndrome. JAMA. Published online January 15, 2026. doi:https://doi.org/10.1001/jama.2025.23666. Butcher BW.
Outcomes after Critical Illness. The New England Journal of Medicine. 2023. Herridge MS, Azoulay É.
Prevalence of Post-Intensive Care Syndrome Among Intensive Care Unit-Survivors and Its Association With Intensive Care Unit Length of Stay: Systematic Review and Meta-Analysis. PloS One. 2024. Ayenew T, Gete M, Gedfew M, et al.
Post-Intensive Care Syndrome as a Burden for Patients and Their Caregivers: A Narrative Review. Journal of Clinical Medicine. 2024. Schembari G, Santonocito C, Messina S, et al.
Post-Intensive Care Syndrome: A Concept Analysis. International Journal of Nursing Studies. 2021. Yuan C, Timmins F, Thompson DR.
Post-Intensive Care Syndrome and Its New Challenges in Coronavirus Disease 2019 (COVID-19) Pandemic: A Review of Recent Advances and Perspectives. Journal of Clinical Medicine. 2021. Nakanishi N, Liu K, Kawakami D, et al.
Communicating to Patients and Families About Post-Intensive Care Syndrome. Chest. 2025. Rolfsen ML, Wilcox ME, Mart MF, et al.
Delirium-Related Psychiatric and Neurocognitive Impairment and the Association With Post-Intensive Care Syndrome-a Narrative Review. Acta Psychiatrica Scandinavica. 2023. Ramnarain D, Pouwels S, Fernández-Gonzalo S, Navarra-Ventura G, Balanzá-Martínez V.
Prevalence and Incidence of Post-Intensive Care Syndrome Among Intensive Care Unit Survivors: A Systematic Review and Meta-Analysis. Annals of Medicine. 2026. Zare-Kaseb A, Sanaie N, Sarmadi S.
Resource Document on the Neuropsychiatric Symptoms of Subacute and Chronic Long COVID. American Psychiatric Association (2024). 2024. Aisha Gillan MD, Melissa Peace MD, Davin Quinn MD, Jon Levenson MD, Thida Thant MD
Post Intensive Care Syndrome (PICS): An Overview of the Definition, Etiology, Risk Factors, and Possible Counseling and Treatment Strategies. Expert Review of Neurotherapeutics. 2021. Ramnarain D, Aupers E, den Oudsten B, et al.
Post-Intensive Care Syndrome After Critical Illness: Incidence and Predictors in a Nationwide Cohort. Anaesthesia. 2026. Oh TK, Song IA.
Guideline on Multimodal Rehabilitation for Patients With Post-Intensive Care Syndrome Critical Care. 2023. Renner C, Jeitziner MM, Albert M, et al.
Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference. Critical Care Medicine. 2012.
Nice review. Just as critical illness is often, itself, a multi-organ process, PICS follows suit. Having tried to pull together an appropriately multi-disciplinary PICS clinic in my own institution, it is easy to see why there are only 35 that you can readily identify. Who was interested? The intensivist. Rehab, neurology, speech, etc. not so much. Why? There was no mechanism for billing for their specialty work. Take rehab medicine, for example. CMS will pay for post-trauma care, post-stroke care, post-neurosurgical care, post-orthopedic care, even post-MI care, but there is no code for post-ICU general care, i.e. it is not recognized. Any administrator can see that the above named conditions impair function in specific ways. What insurance company or CMS administrator understands the generalized impairment that comes from a broad variety of critical illnesses? Hence, my colleagues, not being able to bill for anything in particular, chose not to participate. Multi-organ failure led to multi-specialty breakdown.
Something worth pointing out is that there is now an ICD-CM code for post-sepsis syndrome, Z51.A. Even though there are no specific diagnostic criteria, other than having had sepsis. Sepsis, by the way, like COVID-19, need not involve ICU care to result in long-lasting neurocognitive and physical deficits. Given that sepsis-induced delirium or encephalopathy is one of the most frequently encountered organ dysfunctions, this should not be surprising. (BTW, a pet peeve is when even gerontologists say "old people get delirious with infection" - yes, they do when they have infection-induced CNS dysfunction. It should be our business to determine why older brains are particularly susceptible to dysfunction, for heaven's sakes.) Having ranted, I'll return to the key point of the paragraph - infections don't rely on having put you into an ICU in order to engender PICS-type impairment.
Finally, I'll point out a conundrum. It's intensivists who are most aware of PICS. Yet it is intensivists who are perhaps least prepared for treating it. Knowing how to care for shock and knowing that your care leads to post-ICU impairments are different from having expertise at actually caring, in the long term, for patients who have those impairments. The skill sets are almost diametrically opposed, and the interest level quite possibly similar. Intensivists tackled the problem of sepsis and awareness of it among other physicians precisely because we saw the devastating downstream effects of missing it or ignoring it in its early course. It was a natural direction to go, and it kept us in the ICU. PICS would take us out of the ICU and into clinic. That stage migration (Will Rogers) effect could wind us up with both worsening ICU and clinic outcomes. Fascinating.
That was beautifully written. And I don't say "beautifully" very often - haha.