Post-ICU Syndrome: A Growing Burden for Outpatient Internists

Post-ICU Syndrome A Growing Burden for Outpatient Internists

---

---

 Check out our extensive video library (see channel for our latest videos)

---

---

Introduction

The landscape of critical care medicine has transformed dramatically over the past decades, with substantial improvements in intensive care unit (ICU) mortality rates leading to an unprecedented number of ICU survivors entering the healthcare system. With a decrease in mortality of critically ill patients in recent years, intensive care medicine research has shifted its focus on functional impairments of intensive care units (ICU) survivors. ICU survivorship is characterized by long-term impairments of cognition, mental health, and physical health. This demographic shift has brought to the forefront a previously underrecognized clinical phenomenon that has profound implications for outpatient internal medicine practice.

Attendees of a 2010 meeting of the Society of Critical Care Medicine coined the term Post Intensive Care Syndrome (PICS) to describe new and persistent declines in physical, cognitive, and mental health functioning that follow an ICU stay and for which other causes, such as traumatic brain injury (TBI) or cerebrovascular accident (CVA), have been excluded. Since 2012, these impairments have been summarized with the umbrella term Post-Intensive Care Syndrome (PICS). These functional impairments have been summarized under the term Post-Intensive Care Syndrome (PICS) since 2012.

The emergence of PICS as a recognized clinical entity represents more than an academic exercise in nosology; it reflects a fundamental shift in how we conceptualize recovery from critical illness. Surviving critical illness does not always equate to recovery, with its aftermath frequently complicated by post-intensive care syndrome (PICS). This syndrome consists of a collection of new or worsening impairments in the physical, psychological, or cognitive domains that develop after critical illness. This paradigm shift has particular relevance for outpatient internists, who increasingly serve as the primary coordinators of care for PICS patients navigating the complex transition from acute critical illness to community-based recovery.

The magnitude of this challenge cannot be overstated. In the 10 years since post-intensive care syndrome was first proposed, research has greatly expanded. Here, we summarize the recent evidence on post-intensive care syndrome regarding its pathophysiology, epidemiology, assessment, risk factors, prevention, and treatments. Yet despite this expanding research base, major gaps persist in our understanding of optimal care delivery models, particularly in the outpatient setting where most PICS management occurs.

This comprehensive review examines PICS through the lens of outpatient internal medicine practice, analyzing the syndrome’s clinical manifestations, epidemiological burden, risk factors, and economic implications. We explore the current state of primary care physician awareness and preparedness, examine existing intervention models, and propose evidence-based strategies for improving care delivery. The analysis aims to provide internists with practical insights for managing this growing patient population while highlighting opportunities for healthcare system improvement.

 

---

Literature Review

Definition and Clinical Manifestations of PICS

Analysis identified the defining attributes of post-intensive care syndrome as: (1) new or worsening multidimensional impairments; (2) physical dysfunction; (3) psychological disorder; (4) cognitive impairment; (5) failed social reconstruction; and (6) persistent impaired multidimensional symptoms extending beyond intensive care and hospital discharge. This comprehensive definition encompasses the complex, interconnected nature of PICS, emphasizing that recovery from critical illness extends far beyond physiological stabilization.

Physical Domain

The physical manifestations of PICS are perhaps the most immediately apparent to clinicians and patients alike. Beyond impairments in the three PICS domains, critical illness survivors frequently suffer from chronic pain, dysphagia, and nutritional deficiencies. Furthermore, they have a higher risk for osteoporosis, bone fractures, and diabetes mellitus. Fatigue should prompt evaluation for possible anemia, nutritional deficits, sleep disturbance, muscular deconditioning, and neurologic impairment. Other common problems include poor appetite with possible weight loss, falls, and sexual dysfunction.

The concept of ICU-acquired weakness represents a particularly challenging aspect of PICS physical manifestations. This encompasses both critical illness polyneuropathy and myopathy, conditions that can persist for months to years following ICU discharge. The implications for outpatient internists are immense, as these patients present with complex rehabilitation needs that require coordination with multiple specialists including physiatry, physical therapy, and occupational therapy.

Cognitive Domain

Cognitive impairments following critical illness represent one of the most debilitating aspects of PICS, often profoundly affecting patients’ ability to return to work and maintain independence. ICU survivors may experience cognitive deficits in memory and attention, with a slow-down of mental processing and problem-solving. These deficits can range from subtle executive function problems to severe cognitive impairment resembling dementia.

The mechanisms underlying PICS-related cognitive dysfunction are multifactorial, involving direct neurological injury from hypoxia or hypotension, inflammatory processes, metabolic derangements, and the effects of sedation and delirium during the ICU stay. Cognitive impairments have been identified as significant under-recognised negative sequelae of postintensive care syndrome. No treatment guidelines exist for cognitive interventions addressing the devastating consequences of impairments and their potential impact on outcomes of intensive care unit (ICU) survivors.

Psychological Domain

The psychological manifestations of PICS encompass a spectrum of mental health conditions that can significantly impact recovery and quality of life. Psychological morbidities, posttraumatic stress disorder, anxiety disorder, and depression also often occur in the post-intensive care unit patient. These conditions are more common among patients with a history of delirium, prolonged sedation, mechanical ventilation, and acute respiratory distress syndrome.

Intensive care unit (ICU) survivors experience longstanding psychological impairments that persist in the months to years following ICU discharge, regardless of severity of illness or extent of physical recovery. Intensive care unit (ICU) survivors experience longstanding psychological impairments that persist in the months to years following ICU discharge, regardless of severity of illness or extent of physical recovery. The persistence of these psychological symptoms poses particular challenges for outpatient internists, who must differentiate between PICS-related psychological symptoms and primary psychiatric conditions.

Epidemiology and Prevalence

The epidemiological burden of PICS has become increasingly well-characterized through large-scale prospective studies. According to the initial findings of the PICS outpatient clinic at the Charité, Campus Virchow Klinikum, 72% (298/417) of patients suffer from impairment in at least one PICS domain three months after discharge from an ICU. This finding aligns with other international studies demonstrating that PICS affects the majority of ICU survivors.

The distribution of PICS manifestations varies considerably among survivors. Participants exhibited eight subtypes of post-intensive care syndrome: post-intensive care syndrome free (50.3 %), impaired in physical (3.4 %), mental (13.5 %), cognitive (12.4 %), physical and mental (7.8 %), physical and cognitive (2.3 %), mental and cognitive (4.0 %) and all three domains (6.3 %). This heterogeneity in presentation underscores the complexity of PICS and the need for individualized assessment and management approaches.

Risk Factors

Understanding risk factors for PICS development is crucial for outpatient internists to identify high-risk patients and implement appropriate screening protocols. Significant risk factors for PICS included older age, female sex, previous mental health problems, disease severity, negative ICU experience, and delirium. Significant risk factors for PICS included older age, female sex, previous mental health problems, disease severity, negative ICU experience, and delirium.

Age, unemployment, education, comorbidities, unplanned admission, longer stay, and place of discharge were risk factors for each domain. Age ≥ 65 years (OR 9.234, p < .001), female gender (OR = 5.143, p = .002), two or more comorbidities (OR = 8.701, p = .002), and discharge to an extended care facility (OR = 36.040, p < .001) were associated with increased probability of impairment in all three domains.

The identification of discharge destination as a major risk factor has particular relevance for outpatient internists. Discharge to an extended care facility was one of the most significant risk factor for the occurrence of each domain and intensity of post-intensive care syndrome. Discharge to an extended care facility was one of the most notable risk factor for the occurrence of each domain and intensity of post-intensive care syndrome. This finding suggests that patients requiring extended care facility placement represent a particularly vulnerable population requiring enhanced monitoring and intervention.

PICS-Family (PICS-F)

The burden of PICS extends beyond the patient to encompass family members and caregivers. The burden of ICU survivors extends to families too, leading to the so-called PICS-family (or PICS-F), which entails the psychological impairments suffered by the family and, in particular, by the caregiver of the ICU survivor. Moreover, family members are also impacted as recognized by the term, PICS-Family (PICS-F).

This recognition of family impact is crucial for outpatient internists, as family members often serve as primary caregivers and may themselves require assessment and support. A key association was demonstrated between a high level of ICU survivors’ anxiety and high levels of ICU relatives’ burden. Strain-related symptoms and sleep disorders were problems encountered by ICU relatives with PICS-F.

---

Economic Burden and Healthcare Costs

The economic implications of PICS represent a substantial and often underappreciated burden on healthcare systems globally. The costs associated with PICS extend far beyond the acute ICU stay, creating long-term financial challenges for patients, families, and healthcare systems.

Direct Healthcare Costs

ICU patients have three to five times higher healthcare costs per day alive compared to a control population. ICU patients have three to five times higher healthcare costs per day alive compared to a control population. Median healthcare costs per day alive for the ICU population were remarkably higher during the year before (€8.9 (IQR €2.4; €32.1)) and the year after ICU admission (€15.4 (IQR €5.4; €51.2)) compared to the control group ((€2.8 (IQR €0.7; €8.8) and €3.1 (IQR €0.8; €10.1)).

The persistence of elevated healthcare costs following ICU discharge reflects the complex, chronic nature of PICS. Our systematic review demonstrates that sepsis survivors incur high healthcare costs that can persist for years after discharge from initial hospitalization. Our systematic review demonstrates that sepsis survivors incur high healthcare costs that can persist for years after discharge from initial hospitalization. Across studies, the median total healthcare cost among sepsis survivors in year one after discharge was $28,719 (IQR $21,715) and the median total healthcare cost in year two after discharge was $22,460 (IQR $14,407). The median cost of a readmission for sepsis survivors was $20,320 (IQR $4,889).

Financial Toxicity

The concept of financial toxicity has emerged as a critical consideration in PICS management. As part of the “post-intensive care syndrome” (PICS), these survivors often experience, in addition to physical and emotional challenges of PICS, major financial burdens resulting from their prolonged ICU treatments. The escalating costs of ICU care, coupled with the potential long-term effects on survivors’ ability to work and maintain financial stability, have brought financial toxicity to the forefront of health care discussions.

The impact on employment and economic productivity represents an important component of PICS-related financial burden. Of the 67.9% of patients who were working and 93.9% driving prior to hospitalization, only 24.6% and 73.2% had returned to those activities, respectively. This dramatic reduction in return-to-work rates has profound implications for both individual families and broader economic productivity.

Quality of Life Impact

The economic burden of PICS must be considered alongside its impact on quality of life measures. Mobility, personal care, usual activities and pain/discomfort in QoL were the domains most affected by PICS. The results of this review showed the adverse effects of PICS and PICS-F on QoL. PICS and PICS-F strongly impact the rehabilitation process and are measured in terms of health costs, financial stress and potentially preventable readmission.

---

Primary Care Physician Preparedness and Awareness

The management of PICS patients in outpatient settings primarily falls to internists and other primary care physicians, yet evidence suggests major gaps in preparedness and awareness among these practitioners.

Current State of Awareness

A comprehensive survey assessing primary care physician awareness of PICS revealed concerning findings about clinical preparedness. Sixty-two percent reported feeling comfortable caring for patients after a critical illness and 75% felt they were aware of common problems encountered after critical illness. However, 84% also thought more education about PICS/PICS-F would be helpful as would a list of common problems seen after critical illness (91%).

This paradox between perceived competence and desired additional education suggests that while many internists feel generally prepared to manage post-ICU patients, they recognize major knowledge gaps when it comes to the specific complexities of PICS. Vital gaps and barriers to providing optimal post-ICU care by PCPs exist. Providers identified time constraints and educational gaps as domains needing attention.

Care Coordination Challenges

The complexity of PICS management creates substantial challenges for primary care coordination. Despite the growing awareness of these issues, structured post-ICU follow-up remains inconsistent, leaving a gap in care that general practitioners (GPs) must often fill. This review examines the role of GPs in managing post-ICU patients, outlining common complications, screening tools, rehabilitation strategies, and potential areas for improved collaboration between primary care and ICU teams.

Yet, patients and caregivers have described post-ICU care as inadequate and fragmented. ICU follow-up clinics could improve post-ICU care, but there is insufficient evidence for their effectiveness. This fragmentation of care places additional burden on outpatient internists, who must navigate complex medical issues without adequate support systems or standardized protocols.

Clinical Assessment Challenges

The assessment of PICS in outpatient settings presents unique challenges for internists. After ICU discharge, patients should be screened for depression, anxiety, insomnia, and cognitive impairment using standardized screening tools. Physicians should also inquire about weakness, fatigue, neuropathy, and functional impairment and perform a targeted physical examination and laboratory evaluation as indicated; treatment depends on the underlying cause.

However, the implementation of systematic screening protocols remains inconsistent across primary care settings. Assessment of psychological symptoms in ICU patients and survivors remains inconsistent and many do not receive appropriate psychological evaluation, diagnosis, or treatment. Screening patients for psychological impairments early and serially following hospitalization is crucial to addressing patients’ needs and mitigating long-term distress, as is connecting patients to outpatient mental health follow-up for treatment.

---

Interventions and Treatment Approaches

The management of PICS requires multidisciplinary approaches that span the continuum from ICU prevention strategies to long-term outpatient rehabilitation. Understanding the evidence base for various interventions is crucial for internists coordinating care for PICS patients.

Post-ICU Clinic Models

Specialized post-ICU clinics have emerged as one approach to addressing the complex needs of PICS patients. Post-ICU clinics are one way to help patients with PICS and to assist patients in their recovery progress. We report herein how we have structured our ICU recovery clinic and highlight important elements to consider when evaluating patients in a post-ICU clinic, including a new mnemonic, IMPORTANCE: ICU debriefing, medications and immunizations, PICS evaluation, organ failure assessment, referrals, testing, addressing future goals of care, needs assessment, caregiver support, and education about expectations.

However, the evidence for effectiveness of post-ICU clinics remains limited. We found insufficient evidence, from a limited number of studies, to determine whether ICU follow-up services are effective in identifying and addressing the unmet health needs of ICU survivors. Follow-up services for improving long-term outcomes in ICU survivors may make little or no difference to HRQoL at 12 months.

Results: Authors discussed very diverse interventions in 15 publications, and 9 reported some level of intervention effectiveness. Conclusions: Although ICU follow-up clinics exist, evidence for interventions and effectiveness of treatments in these clinics remains underexplored.

Clinical Outcomes from Post-ICU Clinics

Real-world data from post-ICU clinics provides insights into the scope of PICS manifestations and intervention needs. In our cohort, 36%, 39.6%, and 17% of patients screened positive for cognitive impairment, anxiety and/or depression, and PTSD respectively. 42.3% of patients had lower extremity mobility impairment. 57.6% of patients required at least one referral after clinic. These findings demonstrate the high prevalence of multidomain impairments and the substantial need for specialized interventions.

The healthcare utilization patterns following post-ICU clinic visits further illustrate the ongoing complexity of PICS management. By one year, 34% of patients had hospital re-admissions with 5% requiring the ICU. The analysis of treatment frequency revealed that half of all patients visited the PICS outpatient clinic in addition to their family physician’s practice in at least two three-month periods after their ICU discharge.

Nonpharmacologic Interventions

The evidence base for specific interventions to address PICS remains limited but provides some guidance for clinical practice. There is thin evidence that diaries and exercise programs have a positive effective on mental outcomes. Despite outcomes favoring the intervention group, other commonly used nonpharmacologic interventions in daily ICU practice are not supported by conclusive evidence from this meta-analysis.

Exercise regimens are beneficial for reducing several post-ICU complications. This finding supports the importance of early mobilization and structured rehabilitation programs for PICS patients, interventions that outpatient internists can coordinate through referrals to physical therapy and cardiac rehabilitation programs.

Cognitive Interventions

The evidence for cognitive interventions remains particularly sparse. Although various cognitive intervention approaches have shown some positive effects on outcomes of ICU survivors after hospital discharge, the high risk of bias and high heterogeneity across studies preclude conclusions about the most appropriate post-ICU care to rehabilitate cognitive deficits in critical care survivors. This review highlighted a number of methodological limitations that require further investigation.

Challenges in Intervention Development

The development and evaluation of PICS interventions face various methodological challenges. Twelve studies (19%) used intervention development frameworks, whereas 24 studies (39%) engaged stakeholders in development processes. The median consent rate was 48% (IQR, 34%-68%). Thirteen of the 22 studies (59%) designed to test efficacy achieved their sample size.

These challenges in research implementation reflect broader difficulties in addressing PICS systematically. Few studies reported applying theory-informed methods or engaging stakeholders in intervention development, suggesting opportunities for improving the evidence base through more rigorous methodological approaches.

---

System-Level Considerations

The effective management of PICS requires consideration of healthcare system factors that influence care delivery and outcomes. These system-level considerations are particularly relevant for outpatient internists who must navigate complex care coordination challenges.

Care Continuity and Coordination

One of the most important challenges in PICS management is ensuring continuity of care across the spectrum from ICU to community-based care. The care of a patient in the intensive care unit extends well beyond his or her hospitalization. Evaluation of a patient after leaving the intensive care unit involves a review of the hospital stay, including principal diagnosis, exposure to medications, period spent in the intensive care unit, and history of prolonged mechanical ventilation.

The transition from hospital to outpatient care often involves multiple handoffs and potential information loss. Information loss can occur at any transition point, and ICU or hospital readmissions are also possible along the pathway. This fragmentation of care places additional burden on outpatient internists to reconstruct critical information about the ICU stay and its potential long-term implications.

Resource Allocation and Healthcare Utilization

The management of PICS patients requires extensive healthcare resources across multiple domains. Post intensive care syndrome (PICS) is a typical complication of critically ill patients during or after their stay in intensive care unit (ICU), characterized by a high incidence and impairment rate. It markedly impacts the quality of life of patients and their families, as well as consumes a substantial amount of medical resources.

Fifty-seven percent of respondents thought a specialized transitional post-ICU clinic would be helpful. Dedicated post-ICU clinics might provide a bridge to transition care post-critical illness back to primary care providers. This suggests that structured transitional care models may help address some of the coordination challenges faced by outpatient internists.

Prevention Strategies in the ICU Setting

While outpatient internists primarily manage established PICS, understanding prevention strategies implemented during the ICU stay is crucial for anticipating patient needs and outcomes. The bundle is an evidence-based, multicomponent set of intensive care unit (ICU) interventions that could be applied to most patients and could have the value of reducing the burden of post-intensive care syndrome. The bundle is an evidence-based, multicomponent set of intensive care unit (ICU) interventions that could be applied to most patients and could have the value of reducing the burden of post-intensive care syndrome.

The implementation of evidence-based prevention bundles during ICU care may influence the severity and manifestations of PICS that internists encounter in outpatient settings. Hence, preventing PICS and minimizing risk factors by optimizing ICU care is of great importance, e.g. by implementing the ABCDE bundle.

Interdisciplinary Care Requirements

The complex, multidomain nature of PICS necessitates interdisciplinary care approaches that extend beyond traditional primary care models. The specialized, multiprofessional care of patients who have been discharged from an ICU, and of their family members, requires an understanding of the complex pertinent risk factors and courses of illness. It would be desirable for cross-sector care strategies to be established with better integration of rehabilitative services, specialized aftercare facilities, nursing facilities, and primary care practices.

This need for integrated care coordination presents both challenges and opportunities for outpatient internists. Strategies to reduce this burden will not only be needed within the ICU setting but will also have to take place in an interdisciplinary, multifaceted approach in primary care settings.

---

Quality of Life and Functional Outcomes

The ultimate goal of PICS management extends beyond addressing individual symptoms to improving overall quality of life and functional outcomes. Understanding these broader outcomes is essential for outpatient internists to establish appropriate treatment goals and monitor progress.

Multidimensional Quality of Life Impact

Taken together, these sequelae reduce their health-related quality of life. Additionally, ICU survivors are challenged by social problems such as isolation, economic problems such as treatment costs and lost earnings, and return to previous employment. The multidimensional nature of quality of life impairment in PICS requires comprehensive assessment approaches that go beyond traditional medical measures.

These impairments negatively impact survivors’ quality of life and their return to work or usual activities. The functional impact of PICS extends to fundamental activities of daily living, requiring internists to consider broad rehabilitation needs and coordinate care across multiple specialties.

Social and Economic Outcomes

The social and economic dimensions of PICS recovery represent critical but often underaddressed aspects of care. At a time that would otherwise represent peak economic productivity, parents of critically ill children often must cut back on work hours or withdraw from employment completely, resulting in financial consequences that persist long after the illness. While this example focuses on pediatric cases, similar patterns affect adult PICS patients and their families.

The inability to return to previous employment levels represents a major challenge for many PICS patients. These psycho-cognitive impairments might be coupled with ICU-acquired weakness (polyneuropathy and/or myopathy), further reducing the quality of life, the ability to return to work, and other daily activities.

Long-term Recovery Patterns

Understanding the trajectory of PICS recovery is vital for setting appropriate expectations and treatment goals. PICS poses an increased burden on the health care system and has a negative societal impact. There are ongoing efforts to understand risk factors for PICS-related impairments; design and evaluate interventions for specific impairments (including the use of an ARDS survivorship core outcome set); and refine and evaluate ICU recovery clinics to support and treat survivors and their families.

The heterogeneity in recovery patterns among PICS patients requires individualized approaches to care planning. The type with impaired in both mental and physical domains was the most prevalent in cases of co-occurrence, suggesting that patients with multiple domain involvement may require more intensive and prolonged interventions.

---

Future Directions and Research Needs

The field of PICS research and clinical management continues to evolve rapidly, with several areas requiring additional investigation and development. Understanding these emerging directions is important for outpatient internists to stay current with evolving best practices.

Research Priorities

Clinical and basic research are still needed to elucidate the mechanistic insights and to discover therapeutic targets and new interventions for post-intensive care syndrome. Future studies need to identify effective components of post-ICU recovery interventions and determine which patient populations may benefit most from ICU recovery services.

The need for more robust intervention studies is particularly acute. To improve recovery programs for ICU survivors, more evidence is needed from robust intervention studies using standardized outcomes. This research gap directly impacts outpatient internists, who must make clinical decisions with limited evidence-based guidance.

Methodological Improvements

Current research in PICS interventions faces important methodological challenges that limit clinical applicability. The predictive performance of most models was excellent, but most models were biased and overfitted. Nonetheless, due to the numerous methodological and reporting shortcomings identified in the studies under review, clinicians should exercise caution when interpreting the predictions made by these models.

Technology and Innovation

Emerging technologies offer potential solutions for some of the care coordination and access challenges inherent in PICS management. Telemedicine and telerehabilitation allow patients with COVID-19 to receive effective care without increasing exposure risk in communities, hospitals, and medical offices. These technological approaches may have broader applications for PICS management beyond the COVID-19 pandemic context.

Personalized Medicine Approaches

The heterogeneity of PICS manifestations suggests opportunities for more personalized approaches to care. A thorough investigation of risk factors across the four domains of PICS is necessary to gain a holistic understanding. The identification and integration of risk factors associated with PICS empower critical care multidisciplinary teams to optimize management strategies, thereby assisting ICU survivors a better recovery. Since multiple risk factors may be simultaneously associated with the four domains of post-intensive care syndrome, it is imperative to develop a comprehensive prediction algorithm.

System-Level Innovations

The development of more effective care delivery models requires system-level innovations that address the complex coordination needs of PICS patients. Improving care for intensive care survivors and their families requires collaboration between practitioners and researchers in both the inpatient and outpatient settings. Strategies were developed to address the major themes arising from the conference to improve outcomes for survivors and families.

---

Clinical Recommendations for Outpatient Internists

Based on the current evidence base and expert consensus, several practical recommendations can guide outpatient internists in managing PICS patients effectively.

Systematic Screening Approaches

Implementing systematic screening protocols is essential for identifying PICS manifestations and coordinating appropriate interventions. This framework supports comprehensive recovery by addressing ICU debriefing, medication management, assessment for PICS (cognitive, psychiatric, and physical impairments), the resolution of organ failures, specialist referrals, follow-up testing, goals-of-care discussions, needs assessment, caregiver support, and education on recovery expectations.

The IMPORTANCE mnemonic provides a structured approach to post-ICU assessment: ICU debriefing, medications and immunizations, PICS evaluation, organ failure assessment, referrals, testing, addressing future goals of care, needs assessment, caregiver support, and education about expectations. This framework can be adapted for use in primary care settings to ensure comprehensive evaluation of PICS patients.

Risk Stratification

Understanding risk factors for PICS development enables internists to identify high-risk patients requiring more intensive monitoring and intervention. To prevent PICS, the multidisciplinary team should pay attention to modifiable risk factors such as delirium and patients’ ICU experience. While some risk factors are non-modifiable (such as age and gender), awareness of risk profiles can guide screening intensity and referral patterns.

To avert the development of PICS, it is imperative for clinicians to closely monitor prognostic factors, including the in-ICU experience and early-onset new symptoms. This monitoring requires coordination with ICU teams to understand the specific experiences and complications that occurred during the critical illness episode.

Multidisciplinary Coordination

The complex nature of PICS requires coordination across multiple specialties and disciplines. Whilst the prevention of PICS is complex, it is important to identify the patients at higher risk of PICS, and clinicians should be aware of the tools available for diagnosis. Stakeholders should implement strategies to achieve PICS prevention and to support its effective treatment during the recovery phase with dedicated pathways and supporting care.

Internists should establish referral relationships with key specialties including physiatry, neurology, psychiatry, pulmonology, and rehabilitation services. Early involvement of these specialists can help address specific domain impairments before they become more severe or chronic.

Patient and Family Education

Education of patients and families about PICS is instrumental for establishing appropriate expectations and promoting adherence to treatment recommendations. Not all elements are required at every visit, allowing for individualized care, but consistent education about the nature of PICS and recovery expectations should be provided.

Family members should be assessed for PICS-F symptoms and provided with appropriate support resources. The burden of ICU survivors extends to families too, leading to the so-called PICS-family (or PICS-F), which entails the psychological impairments suffered by the family and, in particular, by the caregiver of the ICU survivor. The development of PICS (and PICS-F) is likely multifactorial, and both patient- and ICU-related factors may influence it.

Documentation and Communication

Effective management of PICS requires detailed documentation of ICU experiences, current symptoms, and treatment responses. This documentation should be shared across the care team to ensure continuity and avoid duplication of assessments or interventions.

Communication with ICU teams, when possible, can provide valuable insights into specific risk factors and potential complications. Understanding the details of mechanical ventilation duration, delirium episodes, and sedation exposure can help predict likely PICS manifestations and guide preventive interventions.

---

---

Conclusion   

Post-ICU Syndrome represents one of the most disturbing emerging challenges in contemporary outpatient internal medicine practice. Post intensive care syndrome (PICS) is a typical complication of critically ill patients during or after their stay in intensive care unit (ICU), characterized by a high incidence and impairment rate. It notably impacts the quality of life of patients and their families, as well as consumes a substantial amount of medical resources.

The evidence clearly demonstrates that PICS affects the majority of ICU survivors, with complex manifestations spanning physical, cognitive, and psychological domains. Patients who have been treated in intensive care units (ICUs) display a multitude of physical, cognitive, and/or mental impairments that are collectively called post-intensive care syndrome (PICS). People with PICS have difficulty returning to everyday life. This difficulty returning to everyday life creates substantial challenges for outpatient internists, who serve as the primary coordinators of care for these complex patients.

The economic burden of PICS extends far beyond the acute ICU stay, creating long-term healthcare costs and financial toxicity for patients and families. PICS poses an increased burden on the health care system and has a negative societal impact. Understanding this burden is crucial for healthcare systems and policymakers to develop appropriate resource allocation and support mechanisms.

Current evidence reveals important gaps in primary care physician preparedness for managing PICS patients. While the majority of internists express comfort with general post-ICU care, most acknowledge substantial educational needs regarding the specific complexities of PICS. However, 84% also thought more education about PICS/PICS-F would be helpful as would a list of common problems seen after critical illness (91%). This finding highlights the urgent need for targeted educational initiatives and clinical support resources.

The evidence base for specific PICS interventions remains limited, with most studies showing methodological limitations and modest effect sizes. We found insufficient evidence, from a limited number of studies, to determine whether ICU follow-up services are effective in identifying and addressing the unmet health needs of ICU survivors. Despite these limitations, certain interventions such as exercise programs and systematic screening protocols show promise and can be implemented in current practice.

The heterogeneity of PICS manifestations requires individualized approaches to care planning and coordination. Participants exhibited eight subtypes … syndrome free (50.3 %), impaired in physical (3.4 %), mental (13.5 %), cognitive (12.4 %), physical and mental (7.8 %), physical and cognitive (2.3 %), mental and cognitive (4.0 %) and all three domains (6.3 %). This diversity underscores the need for comprehensive assessment protocols and flexible care coordination approaches.

Looking forward, the growing population of ICU survivors ensures that PICS will become an increasingly important consideration in outpatient internal medicine practice. Increasing numbers of patients survive critical illness. Survivors of critical illness are at risk of post-intensive care syndrome (PICS). Healthcare systems must develop appropriate infrastructure and support mechanisms to address this growing burden effectively.

The multidisciplinary nature of PICS management requires enhanced collaboration between ICU teams, specialist physicians, and primary care providers. Improving care for intensive care survivors and their families requires collaboration between practitioners and researchers in both the inpatient and outpatient settings. This collaboration must extend to include patients and families as active participants in care planning and decision-making.

Several key priorities emerge from this analysis for improving PICS management in outpatient settings. First, enhanced education for internists regarding PICS recognition, assessment, and management is essential. Second, development of systematic screening protocols and clinical decision support tools can help identify high-risk patients and guide appropriate interventions. Third, improved care coordination mechanisms between ICU teams and outpatient providers can facilitate better continuity of care and information transfer.

Fourth, expansion of multidisciplinary care models that integrate physical therapy, occupational therapy, psychology, and social work services within primary care settings can address the complex needs of PICS patients more effectively. Fifth, development of patient and family education resources can help establish appropriate expectations and promote adherence to treatment recommendations.

The evidence also highlights the importance of considering PICS-F and the broader family impact of critical illness recovery. The burden of ICU survivors extends to families too, leading to the so-called PICS-family (or PICS-F), which entails the psychological impairments suffered by the family and, in particular, by the caregiver of the ICU survivor. Internists must be prepared to assess and address family needs as part of comprehensive PICS management.

Research priorities for the future include development of more robust intervention studies with standardized outcome measures, investigation of personalized medicine approaches based on individual risk profiles, and evaluation of innovative care delivery models including telemedicine and digital health technologies. Clinical and basic research are still needed to elucidate the mechanistic insights and to discover therapeutic targets and new interventions for post-intensive care syndrome.

The economic implications of PICS also warrant continued investigation and policy attention. The escalating costs of ICU care, coupled with the potential long-term effects on survivors’ ability to work and maintain financial stability, have brought financial toxicity to the forefront of health care discussions. The current review examines the causes and consequences of financial toxicity. Understanding these economic impacts is crucial for developing sustainable approaches to PICS management and support.

In conclusion, Post-ICU Syndrome represents a critical and growing burden for outpatient internists that requires systematic approaches to education, clinical care, and healthcare system organization. Therefore, early intervention and assessment of PICS is crucial. While substantial challenges remain in developing evidence-based interventions and care delivery models, the current literature provides sufficient foundation for implementing systematic screening protocols, multidisciplinary care coordination, and patient education initiatives.

The successful management of PICS patients requires a fundamental shift in how we conceptualize recovery from critical illness, moving beyond acute stabilization to encompass long-term functional outcomes and quality of life. This shift has profound implications for medical education, clinical practice patterns, healthcare financing, and healthcare system organization. As the population of ICU survivors continues to grow, addressing these challenges becomes increasingly urgent for ensuring optimal outcomes for this vulnerable patient population.

The burden of PICS extends beyond individual patient care to encompass broader questions of healthcare equity, resource allocation, and system capacity. Internists must be prepared to advocate for their PICS patients within healthcare systems that may not yet be fully equipped to address the complex, long-term needs of critical illness survivors. This advocacy role represents an important professional responsibility that will become increasingly vital as PICS prevalence continues to grow.

Ultimately, the effective management of PICS requires sustained commitment from healthcare providers, administrators, policymakers, and researchers to develop and implement evidence-based approaches to this complex clinical challenge. The current evidence base, while imperfect, provides sufficient foundation for meaningful improvements in clinical care and patient outcomes. The opportunity exists for outpatient internists to lead in developing innovative approaches to PICS management that can serve as models for broader healthcare system transformation.

---

References:  

1. Inoue, S., Nakanishi, N., Amaya, F., et al. (2024). Post-intensive care syndrome: Recent advances and future directions. Acute Medicine & Surgery, 11(1), e929.
2. Incidence rate and risk factors for post-intensive care syndrome subtypes among critical care survivors three months after discharge: A prospective cohort study. (2023). International Journal of Nursing Studies, 149, 104627.
3. He, X., Song, Y., Cao, Y., Miao, L., & Zhu, B. (2024). Post intensive care syndrome: A review of clinical symptoms, evaluation, intervention. Heliyon, 10(10), e31278.
4. Post-intensive care syndrome: A concept analysis. (2020). International Journal of Nursing Studies, 114, 103812.
5. Paul, N., & Weiss, B. (2025). Post-Intensive Care Syndrome: functional impairments of critical illness survivors. Der Anaesthesist, 74(1), 3-14.
6. Hiser, S. L., Fatima, A., Dinglas, V. D., & Needham, D. M. (2024). Updates on Post-Intensive Care Syndrome After Acute Respiratory Distress Syndrome: Epidemiology, Core Outcomes, Interventions, and Long-Term Follow-Up. Critical Care Clinics, 45(4), 917-927.
7. Incidence of and risk factors for post-intensive care syndrome among Chinese respiratory intensive care unit patients: A cross-sectional, prospective study. (2022). Heart & Lung, 57, 10-17.
8. Survival ≠ Recovery: A Narrative Review of Post-Intensive Care Syndrome. (2023). Chest Critical Care, 1(1), 100003.
9. Myers, E. A., Smith, D. A., Allen, S. R., & Kaplan, L. J. (2016). Post-ICU syndrome: Rescuing the undiagnosed. JAAPA, 29(4), 34-37.
10. Gravante, F., Trotta, F., Latina, S., et al. (2024). Quality of life in ICU survivors and their relatives with post-intensive care syndrome: A systematic review. Nursing in Critical Care, 29(4), 807-823.
11. Treatment of the post-ICU patient in an outpatient setting. (2009). Critical Care Medicine, 37(3), 1020-1024.
12. Schembari, G., Santonocito, C., Messina, S., et al. (2024). Post-Intensive Care Syndrome as a Burden for Patients and Their Caregivers: A Narrative Review. Journal of Clinical Medicine, 13(19), 5881.
13. Post-intensive care syndrome: A concept analysis. (2020). International Journal of Nursing Studies, 114, 103812.
14. Post-ICU Clinic. (2023). Chest Critical Care, 1(4), 100040.
15. Post-ICU Care in the Outpatient Setting. (2021). American Family Physician, 103(10), 615-621.
16. Post-Intensive Care Syndrome: From Diagnosis To Treatment. (2025). Deutsches Ärzteblatt International, 122(1), 9-16.
17. Survival ≠ Recovery: A Narrative Review of Post-Intensive Care Syndrome. (2023). Chest Critical Care, 1(1), 100003.
18. Myers, E. A., Smith, D. A., Allen, S. R., & Kaplan, L. J. (2016). Post-ICU syndrome: Rescuing the undiagnosed. JAAPA, 29(4), 34-37.
19. He, X., Song, Y., Cao, Y., Miao, L., & Zhu, B. (2024). Post intensive care syndrome: A review of clinical symptoms, evaluation, intervention. Heliyon, 10(10), e31278.
20. Post-Intensive Care Syndrome-Mental Health. (2025). Critical Care Clinics, 41(1), 89-102.
21. Liou, A., Schweickert, W. D., Files, D. C., & Bakhru, R. N. (2023). A Survey to Assess Primary Care Physician Awareness of Complications Following Critical Illness. Journal of Intensive Care Medicine, 38(8), 760-767.
22. Myers, E. A., Smith, D. A., Allen, S. R., & Kaplan, L. J. (2016). Post-ICU syndrome: Rescuing the undiagnosed. JAAPA, 29(4), 34-37.
23. Post-ICU Clinic. (2023). Chest Critical Care, 1(4), 100040.
24. Post Intensive Care Syndrome (PICS): an overview of the definition, etiology, risk factors, and possible counseling and treatment strategies. (2021). Expert Review of Respiratory Medicine, 15(12), 1611-1621.
25. Post-Intensive Care Syndrome: From Diagnosis To Treatment. (2025). Deutsches Ärzteblatt International, 122(1), 9-16.
26. Post-intensive care syndrome: A crash course for general practice. (2021). Australian Family Physician, 50(9), 634-640.
27. Supporting Post-ICU Recovery: A Narrative Review for General Practitioners. (2025). International Journal of General Medicine, 18, 287-309.
28. Survival ≠ Recovery: A Narrative Review of Post-Intensive Care Syndrome. (2023). Chest Critical Care, 1(1), 100003.
29. He, X., Song, Y., Cao, Y., Miao, L., & Zhu, B. (2024). Post intensive care syndrome: A review of clinical symptoms, evaluation, intervention. Heliyon, 10(10), e31278.
30. Schembari, G., Santonocito, C., Messina, S., et al. (2024). Post-Intensive Care Syndrome as a Burden for Patients and Their Caregivers: A Narrative Review. Journal of Clinical Medicine, 13(19), 5881.
31. Su, H., Fuentes, A. L., Chen, H., et al. (2025). The Financial Impact of Post Intensive Care Syndrome. Critical Care Clinics, 41(1), 103-119.
32. Healthcare costs after sepsis: a systematic review. (2025). Critical Care Medicine, 53(2), e45-e58.
33. Burchardi, H., & Schneider, H. (2004). Economic aspects of severe sepsis: a review of intensive care unit costs, cost of illness and cost effectiveness of therapy. Pharmacoeconomics, 22(12), 793-813.
34. Healthcare costs of ICU survivors are higher before and after ICU admission compared to a population based control group. (2017). PLoS One, 12(12), e0189298.
35. Economic burden of hospital malnutrition: A cost-of-illness model. (2022). Clinical Nutrition ESPEN, 49, 74-85.
36. Economic burden of illness imposed by severe sepsis in Austria. (2003). Intensive Care Medicine, 29(8), 1417-1424.
37. Survival ≠ Recovery: A Narrative Review of Post-Intensive Care Syndrome. (2023). Chest Critical Care, 1(1), 100003.
38. Patient Characteristics and Clinical and Economic Outcomes Associated with Unplanned Medical and Surgical Intensive Care Unit Admissions: A Retrospective Analysis. (2023). ClinicoEconomics and Outcomes Research, 15, 723-736.
39. Schembari, G., Santonocito, C., Messina, S., et al. (2024). Post-Intensive Care Syndrome as a Burden for Patients and Their Caregivers: A Narrative Review. Journal of Clinical Medicine, 13(19), 5881.
40. Epidemiology and Costs of Sepsis in the United States-An Analysis Based on Timing of Diagnosis and Severity Level. (2018). Critical Care Medicine, 46(12), 1889-1897.
41. Critical Care Follow-up Clinics: A Scoping Review of Interventions and Outcomes. (2016). Applied Nursing Research, 32, 185-193.
42. Follow-up services for improving long-term outcomes in intensive care unit (ICU) survivors. (2018). Cochrane Database of Systematic Reviews, 11, CD013037.
43. ICU quality improvement. Science.gov Topic Pages.
44. The Cleveland Clinic Post-ICU Recovery Clinic: Early Experience During the COVID-19 Pandemic. (2024). Journal of Intensive Care Medicine, 39(12), 1234-1242.
45. Nonpharmacologic Interventions to Prevent or Mitigate Adverse Long-Term Outcomes Among ICU Survivors: A Systematic Review and Meta-Analysis. (2019). Critical Care Medicine, 47(11), 1607-1618.
46. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference. (2011). Critical Care Medicine, 40(2), 502-509.
47. ICU follow-up services. Science.gov Topic Pages.
48. A Systematic Review of the Development and Implementability of Complex Interventions After Hospitalization for Survivors of Intensive Care. (2025). Chest Critical Care, 3(1), 100042.
49. Post-intensive care outpatient clinic: is it feasible and effective? A literature review. (2018). Revista Brasileira de Terapia Intensiva, 30(2), 146-154.
50. Effectiveness of cognitive interventions on cognitive outcomes of adult intensive care unit survivors: A scoping review. (2021). Australian Critical Care, 34(3), 285-294.
51. Inoue, S., Nakanishi, N., Amaya, F., et al. (2024). Post-intensive care syndrome: Recent advances and future directions. Acute Medicine & Surgery, 11(1), e929.
52. Incidence rate and risk factors for post-intensive care syndrome subtypes among critical care survivors three months after discharge: A prospective cohort study. (2023). International Journal of Nursing Studies, 149, 104627.
53. Hiser, S. L., Fatima, A., Dinglas, V. D., & Needham, D. M. (2024). Updates on Post-Intensive Care Syndrome After Acute Respiratory Distress Syndrome: Epidemiology, Core Outcomes, Interventions, and Long-Term Follow-Up. Critical Care Clinics, 45(4), 917-927.
54. Incidence of and risk factors for post-intensive care syndrome among Chinese respiratory intensive care unit patients: A cross-sectional, prospective study. (2022). Heart & Lung, 57, 10-17.
55. Gao, S., Liang, X., Pan, Z., Zhang, X., & Zhang, L. (2024). Effect size estimates of risk factors for post-intensive care syndrome: A systematic review and meta-analysis. Intensive and Critical Care Nursing, 87, 103888.
56. Risk prediction models for post-intensive care syndrome of ICU discharged patients: A systematic review. (2024). International Journal of Nursing Sciences, 12(1), 45-56.
57. Schembari, G., Santonocito, C., Messina, S., et al. (2024). Post-Intensive Care Syndrome as a Burden for Patients and Their Caregivers: A Narrative Review. Journal of Clinical Medicine, 13(19), 5881.
58. Risk factors for post-intensive care syndrome: A systematic review and meta-analysis. (2019). Intensive and Critical Care Nursing, 57, 102800.
59. Su, H., Fuentes, A. L., Chen, H., et al. (2025). The Financial Impact of Post Intensive Care Syndrome. Critical Care Clinics, 41(1), 103-119.
60. A protocol for tracking outcomes post intensive care. (2021). Journal of Clinical Nursing, 30(15-16), 2351-2361.

 

---

[Internal Medicine -Home]

 

Video Section

---

 

Recent Articles

• Micro-Behaviors and Macro-Mindsets: An Analysis of Subtle Human Reactions
• Burnout vs. Breakthrough: Why Some Doctors Find Joy Again After Leaving Clinical Practice
• The Truth About Physician Financial Myths: What Most Doctors Get Wrong
• Revisiting Lyme Disease Management in Primary Care
• The Psychology of Everyday Life: How Small Behaviors Reflect Deep Cognitive and Emotional Processes
• Managing ADHD in Adults: A Growing Primary Care Responsibility
• Raw Honey and Early Morning Awakening: Clinical Considerations
• Hemophilia Prophylaxis in the Era of Non-Factor Therapies
• Hidden Cognitive Decline Symptoms: What Every Internist Must Know Today
• Alternative Therapies for Depression: Breakthrough Neurostimulation Methods Show 80% Success Rate
• Pediatric Sepsis: Can Rapid Genomic Diagnostics Save Lives?
• Psychedelics for Acute Suicidality: Could the ED Become the Frontline?
• Pulse Pressure Variation: The Missing Key to Fluid Responsiveness in ED
• Screen Time, Social Media, and Teen Mental Health: What Can Family Physicians Do?
• Should Family Physicians Routinely Screen for Depression and Anxiety?
• Why Standard Blood Pressure Targets After Surgery May Be Harming Your Patients
• Evidence-Based Insights into Everyday Human Behavior
• Fascinating Psychological Insights- Evidence-Based Observations About How the Human Mind and Behavior
• Glycine’s Role in Sleep Enhancement- Clinical Evidence, Mechanisms, and Therapeutic Applications
• Early Morning Awakening Syndrome- Understanding Cortisol Dysregulation
• Why GLP-1 Non-Responders Need Earlier Anti-Obesity Medication Intervention
• Tachyphylaxis in Antidepressants: The Science Behind Treatment Resistance
• The Opioid Crisis in Family Practice: Safe Prescribing vs. Abandoning Patients
• 70 Psychology Facts That Explain How the Mind and Behavior Interact
• 100 Timeless Lessons for Growth, Success, and Happiness — With Healthcare Applications
• The Hidden Patterns of the Human Mind Evidence-Based Insights
• Asthma vs. COPD in Primary Care: Are We Missing Asthma-COPD Overlap?
• Lung Cancer Screening in Primary Care: Why Uptake Remains Low
• The Hidden Cost of Skipping Frailty Assessment: New Research Reveals
• The Spectrum of AI Influence- Comparative Impact Across Medical Specialties

   

---