1. Post-intensive care syndrome:
recognized effects of serious illness
on post-discharge functioning
Dan Haupt , MD
Kyle Eric Johnson, MD
Department of Psychiatry Grand Rounds
May 15th 2018

2. Introduction and Background
Marshall University 2010 B.A. and B.S.
MU Joan C. Edwards School of Medicine 2014 MD
OHSU: July 2014-June 2018
Psychiatry Residency
Stanford University July 2018
C/L Psychiatry Fellowship
-Seceded from Confederacy During Civil War 1861, Statehood June
-Capital: Charleston
-Pop: 1,831, est, 38th
-Often lowest (second lowest, Thanks MISSISSIPPI) income, education, health
-Huntington 49, census
-Meth and Opiates; Huntington Opiate Overdose capital of US
-MUJCESOM: 2014
-Heroine 2016 Netflix, We Are Marshall

3. Introduction and Background
OHSU consult service since 2012
Previously at Washington University in St. Louis – Barnes Hospital and Siteman Cancer Center

4. Conflict of Interest Disclosure
Disclosure We do not have any relationships to disclose.

5. Objectives
Participants will learn to recognize symptoms of post-icu syndrome in their patients after hospitalization
Participants will be able to describe strategies to assist identified patients and affected family members adapt to the effects of post-icu syndrome

6. Broadly syndrome: PICS Definition: ADULTS AFTER CRITICAL ILLNESS
Typically excludes those due to TBI/Stroke
NEW or WORSENING functioning in ONE or MORE of the following clinical DOMAINS
-Coined 2010 Raise Awareness of Long term effects following ICU stay/improved survival as most literature in critical care medicine is focused on short term outcomes

7. Cognitive Function
-Classifying neurocognitive disorders: The DSM-5 approach - Scientific Figure on ResearchGate. Available from: [accessed 6 May, 2018] -

8. Psychiatric Function
-Attribution to freepik.com

9. Physical Function STRENGTH Balance MOBILITY Pain
-Attribution from freepik.com all credits to original author flaticon
-ICU Acquired Weakness or Critical Illness Polyneuropathy (25% more survivors)
-64% mobility issues at 6months
-73% moderate to severe pain
-1/4 require 50 hours week care (80% by family members)
-Brain ICU Study (821 patients) 32% disabled/decreased 3months and 12months
-Contractures of elbows, ankles then Hip knee
-ARDS- Decreased lung function, CO2 diffuse capacity, spirometry
Pain
MOBILITY

10. Post Intensive Care Syndrome- Family
PICS-F
-Icon made by [author link] from 
-Impact predominately psychiatric on family members of patients who survive critical illness

11. So Why Do We Care?
-Icon made by [author link] from 

12. It’s potentially a big problem!
5.7 Million US ICU Admission in 2010’s
4.8 Million Will Likely Survive
Up to 50% or More with PICS criteria
-Icon made by [author link] from 
-Poorly studied, most research on short term outcomes, but we’ve gotten much better at keeping people alive
-Utilization of Intensive Care Services, 2011 Marguerite L. Barrett, M.S., Mark W. Smith, Ph.D., Anne Elixhauser, Ph.D., Leah S. Honigman, M.D., M.P.H., and Jesse M. Pines, M.D.
-6-10

13. With Long Term Consequences
-Icon made by [author link] from 

14. Cognitive Impairments
Incidence Range from 25-78%
BRAIN ICU Study: 821 patients, 6% Impaired at Baseline
3 months: 40 % Deficits Similar to Moderate TBI and 26% Had Deficits Similar to Mild Dementia
Deficits Persisted for 12 months in Majority
-Icon made by [author link] from 
-Avg 25%- with some incidences up to 78%
-BRAIN ICU Study- 821 patients

15. Psychiatric Sequelae Absolute Risk Varies 1-62 % (Highest ARDS)
BRAIN ICU STUDY: 28 % Depression, 22% PTSD
Largely Somatic in Nature,
Those with Preexisting Conditions Highest Risk
10% PTSD 3 and 12 months
-Icon made by [author link] from 

16. Physical Limitations 64% Issues with Mobility at 6 months
ICU Acquired Weakness/Critical Illness Polyneuropathy 25%
64% Issues with Mobility at 6 months
73% Reported Moderate to Severe Pain
BRAIN ICU Study:32% Disabled in ADLS at 3months % Disabled in ADLS at 12months
-Icon made by [author link] from 

17. PICS-F PTSD, Depression, Anxiety
25% Reported Needing 50 hours of care per week
80% of which provided by Family Members
-Icon made by [author link] from  1.

18. In addition to the other burdens
-Icon made by [author link] from 
-Walsh TS, Salisbury L, Donaghy E, et al. PReventing early unplanned hOspital readmission aFter critical ILlnEss (PROFILE): protocol and analysis framework for a mixed methods study. BMJ Open. 2016;6(6):e doi: /bmjopen
Cost
25-30% Will Require Readmission Within 3 Months

19. Pathogenesis is Unclear, Likely Multifactorial
Sedation
Immobilization
Poor Nutrition
Inflammation, Sepsis
Disruption of Blood Brian Barrier
Sleep Disturbances
Disruption of Neuronal Mechanisms

20. AND DEFICITS APPEAR INTERCONNECTED
-Icon made by [author link] from 
Though cause and effect not firmly established

21. How can we help?
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22. Outcomes of Treatment After the Fact Seem Poor
Unfortunately,
Outcomes of Treatment After the Fact Seem Poor
-Icon made by [author link] from 
-Only some studies with Early PT/OT seem to improve physical component and even these are mixed with minimal improvement cognitively

23. “An ounce of prevention is worth a pound of cure” -Benjamin Franklin

24. Two Sides of the Same Coin,
Inpatient Realm
Outpatient Realm

25. So, Identify Who is at Risk

26. PRE-EXISTING/PREDISPOSING RISK FACTORS
Underlying Cognitive Disorder
Developmental Disability, Dementia, Stroke, etc
Underlying Psychiatric Disorder
Anxiety, Depression, PTSD, etc
Underlying Physical Disorder
COPD, Neuromuscular Disorder, etc
Psych Specific- Female, >50yo, Low SES, Hx Alcohol/Substance use

27. ICU SPECIFIC RISK FACTORS
Sedation, Medication Effects
Immobilization, Restraints
Infections, Sepsis
ARDS: Mechanical Ventilation
Hypotension/Hypertension
Metabolic and Electrolyte Disturbances
Delirium

28. Delirium Acute Onset (Hours/Days)
Change Baseline that Fluctuates in Intensity
Impaired Attention/Concentration and Awareness
May Have Additional Cognitive OR Affective Disturbances
Physiologic Cause
Delirium: Duration 6-12months
Sepsis 3x more likely 16% vs 6% develop PICS even taking baseline cognitive impairment into account
ARDS: 73% mod/severe cognitive impairment at DC % persisted 1 year, 47% at 2 year
-Hypoxia, Hypotension
-Sedation/Intoxicants

29. Pathophysiology Derangement of Coordinated Neuronal Firing
Inflammation (Infection, Injury)
Cytokine Cascades, Free Radicals
Alteration of Neurotransmitters
Low Acetylcholine
High Dopamine
Serotonin, GABA, Glutamate
Generalized Slowing on EEG
Symptoms
Baseline
Time

30. Delirium Sequelae Decline in Cognitive and Physical Functioning
In some cases long term
New or Worsening Psychiatric Conditions
Increased Morbidity and Mortality
Higher Rates of Readmission
Financially and Emotionally Difficult for Caregivers
Delirium: Duration 6-12months
Sepsis 3x more likely 16% vs 6% develop PICS even taking baseline cognitive impairment into account
ARDS: 73% mod/severe cognitive impairment at DC % persisted 1 year, 47% at 2 year
-Hypoxia, Hypotension
-Sedation/Intoxicants
Step-Wise Decline

31. Delirium / PICS

32. Managing Delirium Behavioral/Environmental: Early Mobilization
Day/Night Cycles (Sleep Consolidation)
Sensory and Orientation Aids
Identify and Encouraging Treatment of Predisposing/Contributing Causes:
Infections, Pain, Nutrition/Hydration, Electrolyte or Hematologic Disturbances
Psychotropic Stewardship:
-Reduction of if Possible/Indicated Medications which Directly or Indirectly Contribute
-Anticholinergics, Benzodiazepines, Opiates, Steroids
Treatment of Agitation/Psychosis:
“Vitamin H”

33. PICS Specific Treatments
ICU diaries
CBT data
PT/OT

34. Greatest Impact
Educating Primary Teams, Nursing Staff, and Caregivers about Delirium and by extension PICS

35. Which Should Extended the Outpatient Realm

36. To Come Full Circle
Including Education and Understanding about PICS and Delirium
Causes
Complications
Outcomes
Identifying Predisposed Patients prior to Hospitalization
Cognitive Assessments to r/o Neurocognitive Disorders in those at Risk
Baseline Psychiatric Symptom Levels
Substance Use Disorders
Psychotropic Stewardship Criteria

37. And Moving Forward
Identifying Patients and Caregivers At Risk Following Hospitalization/Illness
Cognitive Assessments in those at Risk (MOCA)
Close Psychiatric Follow Up/Support
Referral to/or Encouragement of Appropriate Resources (PT/OT, Primary Care, Family Therapy ect)
Psychotropic Stewardship
Serial Assessments
Education of other Providers, Patients, Families and Caregivers regarding PICS/Delirium

38. Psychiatry Inpatient Consult Service:
Team Members: Rotating 2 LIP Attending:
Currently Dr. Amela Blekic Medical Director, Dr. Dan Haupt, Dr. Anne Gross (fellow attending on Thursdays) Dr. Anne Fang (ECT)
1 or More PGY2 Residents
1 Fellow (part time hours)
Medical students rotating
2 RN Professional Practice Leaders:
Julia DeArmond, APRN, PMHNP-BC
Dianne Wheeling, MNE, RN-BC
1 Psychiatric Social Worker:
Andrea Monto, LCSW (started January, 2018)
Occasionally Other Residents, Such as Myself : Kyle Eric Johnson, MD
(Not to be confused with Kyle Patrick Johnson, MD-: no relation)

39. haupt@ohsu.edu kylej@ohsu.edu
Thank You

40. Questions?

41. References
UpToDate Post Intensive Care Syndrome (PICS): Mark E Mikkelsen, MD, MSCE, Giora Netzer, MD, MSCE, Theodore Iwashyna, MD, PhD.
Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Crit Care Med 2012; 40:502.
Wunsch H, Angus DC, Harrison DA, et al. Variation in critical care services across North America and Western Europe. Crit Care Med 2008; 36:2787.
Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med 2013; 369:1306.
Jackson JC, Pandharipande PP, Girard TD, et al. Depression, post-traumatic stress disorder, and functional disability in the BRAIN-ICU study: a longitudinal cohort study. Lancet Respir Med 2014; 5:369.
Davydow DS, Zatzick D, Hough CL, Katon WJ. In-hospital acute stress symptoms are associated with impairment in cognition 1 year after intensive care unit admission. Ann Am Thorac Soc 2013; 10:450
Hopkins RO, Jackson JC. Long-term neurocognitive function after critical illness. Chest 2006; 130:869.
Girard TD, Jackson JC, Pandharipande PP, et al. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med 2010; 38:1513.
Bienvenu OJ, Colantuoni E, Mendez-Tellez PA, et al. Depressive symptoms and impaired physical function after acute lung injury: a 2-year longitudinal study. Am J Respir Crit Care Med 2012; 185:517.
Hermans G, Van Mechelen H, Clerckx B, et al. Acute outcomes and 1-year mortality of intensive care unit-acquired weakness. A cohort study and propensity-matched analysis. Am J Respir Crit Care Med 2014; 190:410.
Jackson JC, Archer KR, Bauer R, et al. A prospective investigation of long-term cognitive impairment and psychological distress in moderately versus severely injured trauma intensive care unit survivors without intracranial hemorrhage. J Trauma 2011; 71:860
Jones C, Griffiths RD, Slater T, et al. Significant cognitive dysfunction in non-delirious patients identified during and persisting following critical illness. Intensive Care Med 2006; 32:923.
Clegg A, Young JB. Which medications to avoid in people at risk of delirium: a systematic review. Age Ageing 2011; 40:23.
Maldonado, Jose. Pathoetiological Model of Delirium: a Comprehensive Understanding of the Neurobiology of Delirium and an Evidence-Based Approach to Prevention and Treatment. Crit Care Clin 24 (2008) 789–856